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• WELL DESTRUCTION PERMIT \/ PU WATERSYSTEM uvea JO SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 600 E MAIN STREET-STOCKTON CA 95202-(209)4468-3420 NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES I YEAR FROM DATE ISSUED JOB ADDRESS CrrrZv CROSS STRE / p APN PARCEL Size LAND USE APP CATION# C OWNER n kw PHONE OWNERADORESS S CITYISTATEZPpppppp COameaCTURnuuum �- / I PHONE T�e)7 CONIIUROR ADDRESS CITY/STATFZP QTI-✓ C67 WELL DRIWND LICENSE NUMBER 3;J i') ESPIRATON DATE PERFORATION CONTRACTOR PHONE PERFORATION CONIIUCTOR ADDRESS CRY/STATEMP X657 Well Drilling License Number Expiration Date Bureau of Alcohol,Tobacco and Fireamis-Users of High Explosives License Number Expiration Data CHP Hazardous Material Transportation for Explosives License Number Expiration Date San Joaquin County Sheriff-Comner Explosives Application and Permit License Number Expiration Data California Occupational Safety Heath-Blaster License Number Expiration Date ReAsoN Fog DESTRuenoN ❑ Dry ❑ Replacemen(.Wall ❑ Caved In ❑ Pg Well ❑ Inactive 'Test Hole Detached/Suspected Well Water C.mminangs) ((��'' Adjacent pmpe"th contamination(Addmss)� l - Known Soil/Water Contaminants at adjacent property EmsmNG WELLCONSTRUCTION DETAILS ❑ Open Bottom ❑ GIawx Na ❑ Uncased ❑ Other Wall Log copy altatlled ❑ Yes ❑ No Grout Saal ❑ No ❑ Yes ft below ground surface(logs) Hole Diameter inches Well Conductor Casing❑ Yes ❑ No DMAhoFConductor Casing ftbgs Dlameterof Conductor Casing Inches Well Casing Diameter inches Total Depth ft Depth to Water ft Depth of Casing It logs D-Ta rnovWCwov Sealing Material from ftbgs to S ftbgs Filler Material from_ft logs to_ft bgs Well using to be mr(orated by one of the following methods: Z24�---- from ft bgs W ft bgs ❑ Mills Knife Number of Cuts every ft and/or ❑ Explosives❑ Detonating mrd ❑ with projectiles everyft ❑ without projectile ❑ Detonating cord and boosters ❑ with projectiles every ft ❑ without projectile ❑ DUNN, Sealing Material eat Cament(94/b bag/56 gal Mata Sand Cement sack mix/7 gal water Bentonite Pellets Bentonfte(20%solds) comer Spec%solids_% Name SPECS on File Specs Submitted Placement Method umped Free Fall Other Seal Completion Complete ushmom ap Complete to Existing Surface Pad I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I 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. MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS f� CONTRACTORSSIGNATURE TITLE DATE I IT I t -/fir _ I ;.. tNI LTH . r � S DEPARTMENT USE ONLY Application Accepted By Date Area Destruction Inspectton By Date Employee IN COMMENTS PE SC Receivetl ChacldN Amount Date PCR, Invoice* Well IDN Codes Info B Cash Remittee Service Re uest* EHD 43-08 WELL DESTRUCTION PERMIT 101507