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0808'ON NVIE:II 9[06 '8 q;j 9wil p9A]939� WELL DESTRUCTION PERMIT P� PUBLIC WATER.SISTEM ❑ Yes ❑ No f� SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPT 1868 East Hazelton Avenue-STOCKTON CA 95ZD54232 - (209) 46834ZO NON-REFUNDABLE PERMIT CALL 209) 953-7G97 FOR INSPECTIONS EXPIRES i YEAR FROM DATE ISSUED JOB ADDRESS KS P ��I� SID 7 p-7 CITY/ZIP .r .�- "Ur1 CROSSSTREET _AFN Q ! ! 4 � 1 25 PARCEL SOEnn•''LAND USSIE AYPLICATONSII OWNER G.IDn PHOAIE24)1-1 4-7 -7-2-7 �Q DINNER ADDRESS �:�c LD/I6 REQ CIMSTATEYZtP J'I'D✓c.7D7'I, 0-fi 'IS -14 -7 I N CONTRACTOR_ Dgif 4erz -17 )C PHONE CONTRACTOR ADDRESS �b [_p C.� -Z3 CITY/STATE)ZIP__,/,/7. C-57 WELL DRILLING LICENSE NUMBER 3 77 9 ExPrRATIONDATE PERFORATION CONTRACTORto 14 --ma PERFORATION CONTRACTOR ADDRESSCITYJSTATEIZIP ❑ C-57 Well Drilling License Number Expiration DateE� Bureau of Alcohol, Tobacco and Firearms - Users of High Fxplosives License Linse Number Expiration Date CHP Hazardous Material Transportation forEtoosives San Joaquin County ShedIT-Coroner ExplosWe9 Application and Permit License Number Expiration Dalf-M-4— License Number Caltfomia Occupational Expiration Date 0 ! Safety Health - Blaster License Number Expiratio REASON FOR DESTRUCTION ❑ Dry ❑ Replacement Well ❑ Caved In ❑ Pit Well m Inactive❑ � 11 UAVDefected/Suspected Well Wale rContaminant(s) NME Adjacent property Wthconlamination (Address)L'tz AR AL Known Soil! VJatercontaminantsatadjacent property 9 EN EXISTING WELL CONSTRUCTION DETAILS ❑ Open Bottom Q Gravel Pack ❑ Uncmed ❑ Other Well Log copy attached ❑ Yes M No Grout Seal ❑ t'o ❑ Yes ft bef v ground surface (Cgs) Hole Diameter n inches Weg Conductor Casing ❑ Yes M No Depth of Conductor Casing PM R bgs Diameter of Conductor Casing inches Wen Casing Dfemeter_4p inches Total Depth —/10 It Depth to Watere 7 R Oepth of Casing 56 i- It bgs 1j Seating Material tram / 1 o ft bgs to O R bgs Filler Material e em ent from I (� ftbgs to ! ftbgs Well casing to be perforated by one of the following methods from ft bgs to ft bgs ❑ WIN Knife Number of cuts every r2 and I or ❑ Explosives ❑ Detonating cord ❑ with projectiles every ft ❑ without projectile ❑ Ocher ❑ Delonating cord and boosters ❑ with projectiles every it ❑ without Projectile Sealing Material Neat Cement (94 xb ba9 /5-6 gal water) Sand Cement P sackmixf 7 gal waW Benton ito Pellets Bentonile (20% solids) Manufacturer Spec % solids_% Name Specs on File Specs Submitted Placement Method Pum Free Fall Other Seal Completion Complete with Mushroom Cap (0.3 R bgs Complete to Existing Surface Pad �. IOIa A MIIAiIMJN ANU 1HAt Milt: V11QRK TVILL BE DONE IN ACCORDANCE WITH SAN I JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. 1 ALSO CERTIFY THAT MY REQUIRED LICENSE IS CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION LAWS. iii i Inriu 1P O ADVANCE.NOTICE REQUIRED FOR IrNI%$PEC-11GNS / Q CONTRACTORS SIGNATUR�TITLE 6&IPV DATE T .. LA r ry r-� DQE ARTMENT USE 0 N L.*-rr Application Accepted By�--14 dw 5d. Date Area Destniction Im-spectio By Dale Employee I Date EHD 4305 1015x07 9-d VZ9CZe960Z Invoice N I Well iD# WELL DESTRUCTION PERMIT z j < M i C:: --1 ®c M C= oul sjelll)Q eoueiiund d [£:Z6 96 80 qej