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`ee/ r✓ <br /> WELL DESTRUCTION PERMIT <br /> PU6LIC WATER SYSTEM❑Yea ETZ <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPT 1666 Past Hazelton Avenue.STOCKTON CA 96205.6292-(209)4e&3A20 <br /> NON-REFuNDABLEP@RMir CALL (�:):i)').'i.'�7orJ(Ful(INSI'i.�.In�iRI:. EXPIRES iYEAR FROM DAT9ISSUED <br /> N <br /> .loN AODRE$s T, i CiTv1LP_ n l q_ O- <br /> CROSS STREET n IJ��^S7. APN 1PARCEL s5-1;Va (J^�/sE�APPucAnoN <br /> t'1YI"�s —PINXJE_ _l�(� }�(J <br /> Dy,PNM AaoaM CrMSTATIUMi P !!!7 c�L <br /> J ,fy� � JCONTRACTOR � PHONE <br /> CONTRACTORA.... 7 IfD JAV <br /> g <br /> 6le/ CmlSTAm— i <br /> C-VWELLDRf1JNO LICENSE TION DATE ID <br /> PHOW <br /> pa:FolunnlcoNTRAcroR �I,P.Y'1�(Z1nr��riBZLdI.�ES-�-=—P� <br /> Pwwowm CONTRACTOR AODRL= -✓��I /L�OD�m4�L 'n•CrrdSTATNLIP <br /> d C-57 Well"Ung M fill w,A C Q L.icanta Number <br /> Bureau ofAleohol,Tobacco and Firearms-Users W High Explosives L(OaPso Ah9ntxY 'l 'lk��('�i3�ExpViran a e <br /> CHP Hazardous Material Transportation for Eviosives License Number EM*allon Date <br /> San Jaaquir County Sheriff-Coroner Explosives Application and POrmN License Number Expiration Date <br /> C&Forma Occupational Safety ifealth-Bladet License Number Expiration Data <br /> MSDFSTRUcTIOM ❑ Dry 0 Replacement wall D Caved in !] Pit W611 ( nx!ve ❑ Ted Hole <br /> DetectedI Suspected Well Water Contaminanl(s) 1 <br /> Adjacent property with Contamination(Address) <br /> Wrown Soli f W.-W eonteminants at adlacenl prof-N. <br /> FfIraTIJG WB.I.COR37rRUC•_]jQi,DETAas 13eopen act*." ❑ (,ravel Pack ❑ LWased 13 Other •�'ay`, <br /> We"Loympyatiached ❑ Yes CB"'NO G""sea] ur�Ho ❑ Yes_____ft boowgroundsurface(Dgs) Holealometer :inches <br /> r—. aiameler Of Conductor Casing- inches <br /> VM Conductor Cashl-�yQ Y f3'No t.)epth of Gon•'•-'__.._s waterAS R Depth of casing- cIt bgs <br /> � <br /> rJ1Iel1 Casing DhmNar I!.V— a% Total Depth U Il 1P �- �' <br /> nrnw+lCnON Srrcnlca no*• �0n� rforfl R"to ftbgs <br /> seating MaRarial from DDs to _Q R t>s$ Filter Material —�� <br /> one of the fotlowinq molhods: from _.R bgs to <br /> Well rffifrfg to be�erT_or e by <br /> 131MsXmft Numberofactsevery 11and!of <br /> !3 wi0 pTOJVCilesevV it ❑ adhoulprolectite <br /> B`E7plosLuas T] Detonating cord A ❑ wi6rout projeLlite <br /> 8'OelonaC(rrg oortl and boosters I3' with PTOOCAas every <br /> ❑ Othrr Santl Cement sadr m x 17 gat water Bantanite Pellols <br /> Sealing laiatalel Heat Cement(Be th eag/tr-6 sal mater) Specs an� Specs S <br /> Gentonitef20%solids) facturer Spec 9I$rids----it' Nie q 1 <br /> Macemerd Method ped Free F Other <br /> Seal Conaptation Comptete ushroom Gap ft . <br /> (Nt_RESY C£7iT(FY THAT I HAVE PREPARED THIS APPLiCATLON AND THAT T*IELATIOM� �O CERTIFY THAT 11Y REWIRED LICENSE IS <br /> JOACN1IN COUiiTY ORDMtANCE%STATE LAWS,AND RULES AND RORK VALL BE DONE IN ACCORDANCE MTH SAN <br /> Et3U <br /> JOAQUCURRfiT AND AG7tHE t}y)TH THE GALffORNIA CONTRACTORS STATE LICENSE BOARD AND THAT 1 AM IN COy1PLLANCE WITH ALL <br /> WORKERS CoaltPENSAVON LAWS- <br /> Ofl )AAZ4Ik)1)it )VER .F~iJtf)It;l:IZ1tllillt@I)1=URINSP C1717N5 L <br /> TiTLF1� r/C% "r� DATE <br /> Co1rTAACTaRa <br /> SIGNATOR <br /> l.[41,1,E el S 7 • ',` � . <br /> RE SEC ~--- - . <br /> SW JAE41 <br /> EP►St _, ,..�,,.ZCU� <br /> D {RT NI ENT USE ON ( / <br /> r� <br /> Date Area <br /> AppGfian Accepled 6y f <br /> 0 Data�y/� /SI-/�� EmProyee IOT — <br /> DestrLKWn Inspection By / L - c/r/As , /01C- <br /> - <br /> COMMMTS <br /> T r t <br /> Amount Pa�U Invoice' well log <br /> CHecIRPA <br /> PE SC Received Date Elvlce Re uest 11 <br /> h <br /> Codes Info Cash Remitted O <br /> B <br /> y 5 7 <br /> VpELL DESTRUr,-iION PERMIT <br /> E}7D A3-C8 <br />