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WELL DESTRUCTION PERMIT <br /> PUBUCWATERSYSTEM❑Yoe UffS <br /> SAN JOAQUIN COUNTY EN+ARONMENTAL HPALITI DEPT 1866 East Hazelton Avenue-STOCKTON CA SS203-0232-IZOO)488-3420 <br /> NON-REFUNDABLE PERMIT {%+1 L1. 209 9b34697ITtndgSPIit IP)HS EXPIRES'I YEAR FROM DATE ISSUED <br /> Jon AomEsa i CITYRlP OS <br /> CROSS STREET QiXm ST1 AP14 1 PARCQ.SI Q&&6 APPUaATIDH/ d <br /> OWNER <br /> OWNER ADDRESS I✓`� 1151/1 CPlnlVorfSEATEaIP•C•A- i,— 5lnI�_ <br /> CONTRACTOR . '121& DrieA <br /> CONTRACTOR ADDRESS (Irl MPD.I" Ale <br /> awsTATIEtw t <br /> C.57 WEI.LDRILLNO LICENsc NUMBE ExPIRATiON DATE Irk d <br /> PERronnnDN CONTRACTOR (A�>'�QYI( �=J y�ftSE)_ �, 8ejq P"W O <br /> PERPORATtON CONTRACTOR ADDRESS �.i�f)I �/�/j 7/kMTa L•-fir CITY/SYATE21P , <br /> Q C-57 Wal DritIng OVN N't t44 Q License Number <br /> HUMAU of JUcohol robacco and Firearms-Usars of High Explosives License Number '('�•D Cl•moi 3 xP6ofr n a <br /> CHP Hazardous Material TramporwIcn for F_xptoshres License Number Expiration Data <br /> Sett Joaquin County ShertlF-Coroner Expbsives Applirat}on and Permit Uaense Number Expitalion Date <br /> Caifornla Ocerpallorml Safety Health-Mailer License Nuanber- Erpcallon Date <br /> REasoN>=nrn+DESTRUCna ❑ Dry ❑ Ropfacemant Well ❑ Caved In ❑ Pit VMI M-Fiactiv0 ❑ Test Hole <br /> Detected/Suspected Weil Water Contandnnnl(s)_ �,�, <br /> Adjaoantpropertywith contamination(Address) +l <br /> Known Sol!Water contaminants at adrzcenl Proper av— [ <br /> 1:7QaTMVJELLCONS1TIIC1nCNDETAIl^' fl'bPei schom ❑ Gravel Paa LNrafed 0 011tef <br /> Well Log copy altad)ed O Yes rd"NO G10r2 Seal e"tto ❑ yes_It below ground surface(bgs) Hole DlemeW g lrches �J <br /> WeM Conductor CasiR9❑2 Yes rd'NO Depth ofCoad, '—CAsing 11• Diameter of C*rKtwtof Casing _Inches <br /> WeUCaefAgDtemeler13..�"Irxltes TOWDWI1 Vnk_tt Oaptl/toWafet I D.►[,)_A OepthofCasi[p t?J� -Rdgs <br /> GFrTrtucTlnn SrccTClcA•n0t pptt <br /> Searing Material from _ i(igDr'W_0 ft loss FillerNater[at from _ttbgeto Rbgs <br /> Well casing to be Perforated by one nr the fotiwvino methods: �> ._tt Dgs toe fl bQs <br /> E3 fuTlps Xraft NumbV of Cuts every R aed J or <br /> erEVIC,aves❑ Detonating Cod ❑ wWhp � <br /> rojeasevdy ft 13 vnTitoutprojectile <br /> W Delon"cord and boosters a- trilb preociiies every-Tft ❑ without Projectile <br /> D Olhi r <br /> Seating Material Neat Cement r94 Jb bag/5-6 gaf W10 Sand Cementsad*mfx 17 gal water Bcntonits Pellets <br /> 'tactuver S %sdds 9: Name _ Specs on F-4g ed <br /> Specs St�� <br /> t3entorlita{YO°f.solids} P� Other !R n/� <br /> 1. <br /> PfaCemerd ed <br /> ge(ktod urn pad Free F� <br /> Seal Comglfetfon Complete Rushroom Cap a <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPUCA71ON AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> 30A9U1H COUNTY ORDINANCES, STATE LAWS,AND RULES AND REGULATTONS. J ALSO CERTIFYTHAT THAT IN COMPREQULIANCE <br /> LICENSE 1S <br /> CUPPM4T AND ACTIVE WITH THE CAUPOFMIA,CONTRACTORS SLATE L1L`ENSE BOARD AND THAT 1 AM IN COMPUAkCE 1IUffH ALL <br /> VIORK£RS ccmPENSAT ION LAWS. <br /> MINICS�Ufy1 (01JR ADV.WC Nnl'ICE REQUIRED FOR iNSP'EC ITO WS L <br /> COWMACTofm SIWIATURE <br /> RECENE I ���„n�h�u L <br /> Z <br /> t; I <br /> 1 <br /> SSE`, t5 'r?� 51�t'Y�RONr'E <br /> H I.rk DEP► <br /> t <br /> _D PARTMENT USE ONLY Area <br /> r � Q Date ' r� <br /> Appitcation Accepted 6 G J, ,Da1 <br /> D,An.ction Inspe6w BY <br /> COMMENNTS O ! <br /> C t� 1'40 — 1 <br /> tJnl !J1)W � <br /> �• ParrnlU Invoice fr We11 IDS <br /> Amount Service Re uest fl <br /> PE Sc ReceiveAClCtoet�fU Rernitted Datc <br /> Codes Info _BY a 0 <br /> WELL DESTRUCTION FERMrr <br /> EHD A3-08 <br />