Laserfiche WebLink
-Aug,13. 2018 11:21AM Canepa & Sone. No, 2472 P. 2/3 <br />` wtLL uESTRUCTION PERMIT I� <br />SAN JOAOUIN COUNTY ENVIRONMENTAL HEALTH DEPT <br />NON•REFUNDARjLE PERMIT CALL 209 953 <br />It <br />JOB ADDRESS A(ee, 6drA <br />CROSS STREET }'Ffdli APN.2.7y^O <br />OWNERA <br />f <br />PUBLIC WATRA SYSTEM Q vee I] NO <br />1868 East HBYelton Avonua • STOCKTON CA US205.8232 • (209( 468-3420 <br />-7697 FOR INSPECTIONS EXPIRES 'I YEAR FROM DATE ISSUED <br />CirylZIP / I ti <br />,��� P GEL �`�LAND USE APPLICATION k � e <br />7 <br />CONTRACTOR ADDRESS -i C /HtLl. <br />CITY/STATEJZIP <br />UKYi 4i"1 <br />C-57 WELL DRILLING LICENSE NuMBER__�'Z'-!7J74q <br />EXPIRATION DATE <br />I <br />PERFORATION CONTRACTOR <br />PHONE <br />PERFORATION CONTRACTOR ADDRE33 <br />CrrY/STATE/ZIP <br />❑ C-57 Well Drilling <br />License Number <br />Explrailon Dale <br />Bureau of Alcohol. Tobacco and Flrearma - USerz Of High Explosives <br />Llcenae Number <br />Expiration Dale <br />CHP Hazardoua Material Transportation for Explosives <br />License Number <br />Expiration Dale <br />San Joaquin County Sherif- Coroner Explosives Application and Permit <br />License Number <br />Expiration Date <br />California Occupational Safety Health - Blasler <br />License Number <br />Expiration Dale <br />Rr SOH FOR DESTRUCTION ❑ Dry Cl Replacemoni Well Q Caved In ❑ Pit Well <br />Ina0ve ❑ Test Hole <br />Detected / Suspecl6d Well Water Contaminanr(s) <br />Adjacent property with contamination (Adtlrese) <br />Known Soil / Water conleminants at adjacent property <br />EXI87I1v0 WELL COH31RUCTION DETAILS ❑ Open Bolrom ❑ Gravot Pack 0 Uncased A Other <br />Well Log Dopy allachad ❑ Yo; R No Grout Saal ❑ No X Yes it R below ground eudace (bgs) Nola Olamalar 4 InChea <br />.I Wall Conduclor Canino O Yee � No Depth of Cona for Casing R bgs blsmator of Conduclor Casino inches i <br />o'F•15l/laj Well Caeing Dlgmalar�Inches Total Daplh M -h Depth 10 Water R Dapin of Caeing It bgs I <br />W V DV.STRUCTION Syr.CrnCATION <br />Sealing Material from 1_(I bga to —IH bgs Flllar Materlal from It bgs to fl bgs <br />Well CAsing to be Perforated by 08 Pf the following methods: NIA from n bga to R bgs <br />❑ Mille Knife Number of cuts every n and I or <br />0 Explosives ❑ Deloneling cord D with projectiles every it ❑ without Projectile <br />❑ Detonating cord and boosters ❑ with projectiles every It ❑ without projectile <br />❑ Other <br />Sealing Material Noel Cement (941b beg/ 5.6 gar wslbr) Sand Comant sack mix! 7 gel water Benlonlle Pellets <br />Bentonite (20% solids)­hLawifaclurar Spec % soiids� Name Specs on File Specs SutA�l✓ I <br />Placomont Method um0ed Free Fall Other F <br />Seal Completion Complete with Mushroom Cup n bgs Complete to E7,1.ting Surfoco Pad H } <br />I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN 4 <br />JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS, I ALSO CERTIFY THAT MY REQUIRED LICENSE IS ; <br />CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT f AM IN COMPLIANCE WITH ALL I <br />WORKERS COMPENSATION LAWS. , <br />R ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br />CONTRACTORS <br />Application Accepted By_ <br />Doslrvclion Inspection By <br />PE 8C Received Chockfrl Amount 1e PermI Invoice k Wall Wit <br />[odor info EV.-, Cash Remltleri service RegUoet k <br />PHD43.06�.q. / { r �[ 7�j ��Gj WELL DESTRUCTION PERMIT <br />Received Time"''Aug, l3.�2018 11:40AM No.4008 <br />Y� till/ <br />F Y��N <br />142418 <br />IN C <br />NENO(JN7Y <br />f1T <br />0 <br />E5 <br />Z <br />ISI <br />