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WELL DESTRUCTION PERMIT <br /> PUBLIC 1NATER SYSTEM ❑YEa 315. <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HCALTFI DEPT 1966 East Hazelton AVenuo-STOCKTON CA 96205-6232-(209)466-7420 <br /> NON-REFUNDABLE PERMIT GALL. 2U:1 951-TG97 full IIQII:+ EXPIRES 1 YEAR FROM DATE ISSUCO <br /> JQBAooREss Crtv2iP _ pp O I� <br /> CRoesSrREEr -S hPN 1 PARct:LSl a 7D SEAPPL1CATtONR <br /> owRER,_N1 (-L/ 95 y <br /> _r-t�r�I�n PROW �?d1le- -41-rn <br /> t -� O 1i I.L _CItYATATEfZIP„s M, - <br /> CONVIAI:10RAWRESS <br /> OWMER AODIIESS coNrnncTOR�G_���y,� �il�n)/YL T1Af1 PRONE �Ji(�- aI!_JiPI MOD C1rv15rA �..l <br /> C-"WELLDRb.LNG L1cemsr NWLeGn�7� 1'3tp g11,p ` E%PwAT10N DATE <br /> PERFORATION CONTRACTOR G.Yl J7 ( YA,f+PXt�U e�,,ACYL(��.PHONE 1. <br /> PERFORATION CONTRACTOR AUDRE63 "l24 1A)01D LS -CG 11YISTATdL. <br /> C1 C-57 M11 Drilling Oj%f ut IAA C H ID License Number i e <br /> exam of Alcohol,Tobacco and Firearms-Users of High Explosives LlcwseNumber. slG3. 'Exprat Dale�— <br /> CHP Hazardous Uialertal Transportation for Eupbs)ves License Number Expiration Dale <br /> Sen Joaquin County Sheriff-Coroner Explosives Application and Permit License Number�_Fxpbwion Date <br /> Caih/nia Om+pa9onal--I Health-Blaster License Number Expiration Oate <br /> 3MON rank iDFS n—TION ❑ Dry ❑ Reptacement Well O Caved In ❑ Pit Web 6JIGactiva ❑ Test Hole <br /> Detailedd SuSpecied Well Water Contaminanl(s), 1P14 . %F a .� <br /> Adjacent props"wlhcontarnination(Address) <br /> Knr n Sell f Water contaminants at adjacent prorxfrtY L{m_ <br /> £7JSTWGWELLCOnsT1fUCr"DETAILS 3-Oprn Bottom ❑ GravA Pads O Uncased O (Met Q!' <br /> WellLogmpyalladId O YES el,40 GneutSat l"No O Yes nbeloagrondstatace(bgs) tlolsolameter ���nche5 <br /> WsifCondoMrCAsnxlr' •• e-No Depth afCandraxorr'xing �n''"' WanteterofCondectorCasing1Meg Casing D{ameter i _inctles Totai Depth,�a DeWh W Watcr�/t�A. $ DepthoFCashlg <br /> nRSTRUCTlax S�FCpCI'no� �{� (7 I1 _ from _n W it bus <br /> S-Rag New" Nam -M_T.ADOs to_ fl bgs Filler llalMial <br /> VVI casing to be perfors byoneofthe following meth odc: from�nbgsto flbgs <br /> 13 Was Knife _Nunbor of cuts every n and I or <br /> ,e`E.plaadVas a Delonating cord Cl with projeci8es every R a without pro)ecttle <br /> S^Dalarr+tiarg care and boosters W aith projeows every n a witheul projectile <br /> ❑ Ottnr <br /> Seating mabsI Naar Cement(94 Ib Dag/5-6 gad wafer) Sand Cement sadr milt 17 gal water Bentonite Pellets <br /> its(20%solids)` c%solids_% Name Specs an FlT9 Specs Submitted <br /> PiaaerneDt�BAeUtod Ped Free FAOthu Id � � <br /> Seal Cen>pfe"on Complete ushroom Cap it III e <br /> I HEREBY CERTLFY THAT(HAVE PREPARED THIS APPL1CAMN AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> IS <br /> CURAN13 ACTIVE WITH REGULATIONS. <br /> CALWORNIA CONTRACTORS STATE LICCEMSE BOARD AND-MAT ABA IH COMPLIANCE I <br /> RENT WM ALL <br /> WORXERS COMPENSATION LAWS. <br /> MIN 0&112.4 I luURt DVA I:I Nu'l111;1:111-r-)UII2I;U PUlZ IN5i�ECTfONS <br /> COMTRAGTORSSIGTIA]INR <br /> I \�1A�lrr � S f♦' I <br /> REC � <br /> gEp 5 C,0, <br /> 00 <br /> ntv <br /> E <br /> p fMENT USE ON Y <br /> Date Area <br /> AppGeatian Accepted Dale Empkave ID-'�7 <br /> Destrrrtionkrspee—By <br /> C(NAMENTS It <br /> of N <br /> 77 <br /> Received Checklld Amount Date Permit] i2 Woll IOff <br /> PE ScCash Remitted Service Re uest I) <br /> Codes Inca a 34 IS I <br /> 33 b <br /> VI DESTRUCTION PERfAT <br /> Qi0 A3-0a <br />