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WELL DESTRUCTION PERMIT <br /> t PUBLIC WATER SYSTEM ❑Yes ❑No <br /> SM JO"M COUNTY E.MVI*WWMTAL HEALTH DEPT 1 M6 East HaatMon Avenue-STOCKToN CA 96209-0=-ROq 409-3429 <br /> NON-REFUNDABLE PERwr CALL 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FRoM DATE ISSUED <br /> JosAaoMne 540 S Center Street crrYrar S <br /> �I I n <br /> PN <br /> cores STms,_E Church Street - — Ai � PAMM S¢a`. Luo Uss APft"nom r <br /> owmin PG&E PHOW <br /> ommAaoMaaa 8180 Folsom Blvd Crrv/STATwzp Sacramento <br /> cowmcroM Woodward Drilling PNOME 707 374 4300 <br /> cowrmcroM Ammas 550 River Road CTrYMTATa/U NO Vista <br /> C47 WILL Draiw LK=m Num 710079 E*WAT1CM DATE 7/31/2019 +- --- <br /> Psi OVATnM COMrMACTOM P►pIM ----- <br /> PMVK MATX M COMTMACrom A000mm CITYMATfMP <br /> ❑ Cbl Wed Drag Uoenes Number Expirs6on Dais <br /> Bureau of Alcohol,Tobsrxo and Ftwrrr-Uwn of High Expbshw Uceme Nwrbm b pkmion Dan <br /> CHP Htardous WWW Trarrpatt6on for EVkmo st Lbrw Na~ -_--- Expinillon Due---- <br /> Stn Joagrin County RwWM Carorwr EplaNres Ap*"=and Permit La Nun _- Expbs n Dab <br /> callortta 0ca914Yonsl 9alsly Hesm-Bbsbr L o roe hMrnbsr Fxptsron Dab <br /> ❑ Dry ❑ Rpbm me wd ❑ Cared In ❑ PM woo ❑ trc*m ❑ Tom Hob <br /> DUecld I a.pnyad Wed Wabr contaminant(•) N/A <br /> Adjacent prowty vmh a«rtamkuYon od*ms) N!A — -- <br /> Known Sol(Wabr contanri oft at aaamd pi ops!y-NIA _- <br /> ❑ Open Bottnrn ❑ Gravel Pack ❑ tk+csred ❑ Omer I InkrnMTT <br /> Well Log copy mooned ❑ Yes ❑ No Grout bed ❑ No ❑ Yes t below ground unlace MW Hofs DlswMw Mrhes <br /> Wed Corrtudor Cminp❑ Yoe ❑ Na DpM of Cw*mbr Coming t bgs Dbwely of cantuctor cm" irons <br /> Wed CMbp Dbw4$sr__6_l KA Taal Depth 219 t Dmpih b WsW. t Dpw of Caslrq *bp <br /> f <br /> swing Mabrw trap 219 t bps b0 t bye Flier Materw tom it Cys to t bps /t3 <br /> Wall casing to be�by ------ - *,om t byt to-- It Dys <br /> ❑ Mia Krafts Number of alt awy t and/or <br /> ❑ Exoa@Nm O DMonaling and ❑ wMl prooclNs ewy t ❑ without prajscris <br /> ❑ Dmixa ng oord and boosbnt ❑ YAM plojeades adry t ❑ rrWIMA WVOcdo <br /> ❑ air <br /> Sesiing MobrlslNest Cement(D4 b bmg,"pal«atr send Cement soot mfr 7 gal wmer Ber4oMb Pdete <br /> owftc Nb;m% sGYidt % Name Specs on F'ts Specs 9ubrrriM W <br /> Plaoumrt Method pimped Fns Fd Orm <br /> I"Co npNYon CarpMe cap 3 to 5 It bye Conrplsb to ExkW ng strfres Pad <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK Wel BE DONE MI ACCORDANCE WITH SAN <br /> JOAOIIRN C"M ORDM/ANCES, STATE LAWS, AND RULES AND REGUUITIONS, I ALSO CERTIFY THAT MY REQUIRED LICENSE 13 <br /> CURRENT AND ACTrJE MATH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLLWCE WrrH ALL <br /> WORKERS COMPENSATION LAWS. <br /> MINIMUM 48 HOUR ADVANCE NOTICE REQUIRED FO INSPECTIONS <br /> Coorrmcmm SumATum TITLA DATE 61 :Z I,L� ry <br /> PAY N <br /> ecelviFo <br /> AN 2 2 2019 <br /> *, <br /> �� SAN <br /> e<-- ���C� E �ROUAN COUNTY <br /> HEq NDE ARTMENT <br /> PAR <br /> M E N T USE ON Y <br /> r <br /> ADPce AanpMd BY Dab Area <br /> D@Wucgon Inspealion By - Dab Z EntplpyM b1 <br /> COMMENTS <br /> Cho** Almount coe.a Otto cab service Recum t Invoice/ WIN!a <br /> I-i 0 V-q- — — <br /> EW4s-aa �8�00 / -_.. WEU DESTRUC71DNPERMIT <br /> nYr.t 414/11 ,tom <br />