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WELL DESTRUCTION PERMIT PUBLIC WATER SYSTEM ❑ Yes ❑ No SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPT 1868 East Hazelton Avenue -STOCKTON CA 95205.6232 - (209) 468-3420 NON-RFFHNnABLF PFRMIT CALL 120q) 953-7697 FOR INRPFCTICINS FXPIRFS 1 YFAR FRnM DATE 1RR11Fn JOB ADDRESS - -S ®0144> ��//•• yy g CITY21P A C/ CROSS STT}REET .I APN /4f 7 .+ PARCEL SIZE% L�A,NND USE APPLICATION #,,q � /� �p/ OWNEW ✓J � ' PHONE rlt W)-4Tl4 A2M, !V 10 OWNER ADDRESS ,GO*.WTP Ad CITV/STATFJZIP Yi/✓'�/f� � dZ) CONTRACTOR CANEPA AND SONS, INC. PHONE (209) 532-1136 CONTRACTOR ADDRESS 14384 CUESTA COURT CITY/STATFJZIP SONORA, CA 95370 C-57 WELL DRILLING �ryry LICENSE 4NUMBER 4257490 EXPIRATION DATE y/�07/31 /2020 PERFORATION CONTRACTOR /p'P,,4/I L14AI� GY �c�'A 674 PHONE p �� / (f/�� -�ji S�LJi: 4 PERFORATION CONTRACTOR ADDRESS_1Z�.Z AVF. CITYISTATE21P,,/,66-& -7�V-i> �3 Z y C-57 Well Drilling License Number. i25%dJ Expiration Date 117,=0 Bureau of Alcohol, Tobacco and Firearms - Users of High Explosives License Number Expiration Date T✓� CF,9/; Hazardous Material Transportation for Explosives License Number -- Expiration Date Joaquin County Sheriff -Coroner Explosives Application and Permit License Number Expiration Date 111 +++ I California Occupational Safety Health - Blaster License Number U Expiration Date 1/ REASON FOR DESTRUCTION ❑ Dry ❑ Replacement Well J Caved In ❑ Pit Well ❑ Inactive ❑ Test Hole Detected / Suspected Well Water Contaminant(s) Adjacent property with contamination (Address) Known Soil / Water contaminants at adjacent property EXISTING WELL CONSTRUCTION DETAILS ❑ Open Bottom ❑ Gravel Pack ❑ Uncased /' Other 4" A471 Well Log copy attached ❑ Yes A No Grout Seal ❑ No ❑ Yes _ft below ground surface (bgs) HoleDlarneler inches Well Conductor Casing ❑ Yes ❑ No Depth of Condu/ctor Casing ft bgs Diameter of Conductor Casing inches Well Casing Diameter_® inches Total Depth _ 1i0 -ft Depth to Water ft Depth of Casing ft bgs DESrRUMON SPECrFTCATION Sealing Material from _ft bgs to D ft bgs Filler Material . 3s1�. from G5 ft bgs to ft bgs Well casing to be perfora.o,...y one of the following methods: from ft bgs to It bgs ❑ Mills Knife Number of cuts every ft and / or Explosives Detonating cord ❑ with projectiles every ft ❑ without projectile ❑ Detonating card and boosters ❑ With projectiles every ft ❑ Without projectile ❑ Other Sealing Material Neat Cement (94 lb bag/5-6 gal wafet) Sand Cement 10-3 sackmix /7 gal water Bentonite Pellets Bentonite. 20% solids)�Maauladurer Spec % solids_% Name Specs on File Specs Submitted Placement Method Free Free Fall Other Seal Completion Complete with Mushroom Cap ft bgs omp ete to Ewsbng Surface Pad 1 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 1 AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION LAWS. rAl' f UM/ADVANCE NOTICE REQUIRED F�R IINSS�PEECyTII�OJtj�1S CONTRACTORS SIGNATURE �//.� !r�� TITL ' ✓ �V' l.. / l� DATE J r AR ENT USE ON Application Accepted ByDate4 Destruction Inspection By Date --4 COMMENTS /4411 �Rc�Ls.y i %H/�lry �i� .4el i3 fus i yy hf a 0 41zqcYt4$)r ✓qNF/ FO VRA viyc ?09 0't;RF) ;"4 4e4�' EHD 43-08 Ll,"' - S/ WELL DESTRUCTION PERMIT �7 revised 4/14118 - 7�6 25157- i • v u.�� Hitii I . AR ENT USE ON Application Accepted ByDate4 Destruction Inspection By Date --4 COMMENTS /4411 �Rc�Ls.y i %H/�lry �i� .4el i3 fus i yy hf a 0 41zqcYt4$)r ✓qNF/ FO VRA viyc ?09 0't;RF) ;"4 4e4�' EHD 43-08 Ll,"' - S/ WELL DESTRUCTION PERMIT �7 revised 4/14118 - 7�6 25157-