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r `/ V <br /> WELL DESTRUCTION PERMIT <br /> PUKIC WATER SYSTEM Q Yes ['J N <br /> SAN JOAQU64 COUNTY EWPONMENTAL HEAVRI DEPT 1888 Cast Hatelton Avdnue-9McKtoN CA 06205.6232-(209)466-3426 <br /> NON-REFUNDABLC PERMIT GAl.I ,:q9 953.76911=olt INc,P1. uuH" CXPIRCS 1 YEAR FROM DATE ISSIIFO <br /> J08AobRl=ss (Lint rC CfYval�' isI g a 2 ,. !3 5-;R D$' <br /> C OO�6.0"r WIA{-�Ti _ APN 1 1+ P ELSI r aEAPPLIGATgNp <br /> OWNER A009U"=`A'z 0 (, ,`n..'A 6� <br /> �L, CITY7krAr�Eift�mn .�'�CLtr] r�,f]1) <br /> CONTRACT011—L,�'k'b7iYn 0. &1i2IC&hta PN'c—=�� r`•• a :C9 <br /> CONTRA.TORA00REas (Oj�l-fY3ep-y *4�&1e CITYdsrnlEfza i <br /> CIS?WELL OReLNO LICEN"NLIVBFR Ag-3 EMIRAIWIl DAT& <br /> PERFORATM CONY1tACTOR en Wo onjers.9 I1.r e4t. PHONEg-3 q—,8-1 fTn !� <br /> DEAF*RATMCONTRACTORAbt ESE <br /> b C-57 WaM Drilling (}Y�T1tt.L A GA ID Licw$6 NuOiber El{gv0l 1� _ <br /> St"MofAreohol,Tobacco andFirearms-U&WsdHighExplasNes Liu4t!6oNufnbet9'f .;1KcXVpr,_'tI ae <br /> CHP Hazardau Malerfal Transpanation far EngMives Lk6nse Nubber__ Czpketlon Dads <br /> Sao Joaquin County SherWCormer Expros^res Apprreslron and Parma Libenae Number Expirelron Gals <br /> Cartotnte Occupational Safety Health-Blasier Lice..Number E-wolion Celt <br /> REAsaM.�at DesrAticThoN ❑ Dry EI Replacaraact Wal L) Ca"o th 0 P wpii rwf-oclive ❑ Test Hate <br /> Datecled 1 Suspected Well Water Carnaminant(s) "��fir S , <br /> Adjacent prop"with contamination(Address) n <br /> Known Sari I YValw contaminants at a4acenl prupeaty i5I - { <br /> fcmmK,gyAgtcON6TRmmquDETAILs p�OpenUnitan X13 C3eNiPeck 13 UMsawd 0 Olhor <br /> Wall Log copy attached ❑ Yvs C"NO GrohlSb-J 21116 O Yet.it ekw¢roundsurfaee(W Hold0tamNw /3.La�rnehsa <br /> WatltomdudorGazin t3 Yes (siva Depthocanrs�+�t^,�-(Casing_ ... ..__ _fthrre 22 Diameter of Conductor Casing _inches <br /> WeUcacngwamtleriIndws TotaiDepth_?'1_krk owaltoWaler�r_R Depth ofCaeingIt bas c+� <br /> UFSTn[rCTM'i hPCIRIG'lT0`r �� <br /> SealHay lBatertal from R tGbDs to _Q ftbgs Paw matedal--AI A— from ti bps to M h9s <br /> Wdi easitg to be aerfor by oneal"Tollowing mettrods:_ fmm iT b9L to_Zh� _ft bas <br /> a 91*3 Knife _Number of cuts every _ .rt and t er <br /> ey'EW.sitres 13 Dehonaling cord ❑ wierpTojeclaac erety R 13 without prxgectte <br /> e'Deionaling cord and booslara aa' [Z--ft O wilhoul profectrfa <br /> OUatt <br /> sees"ustarlaai Neat Cement(94 fb begr'5.6 ya(scoter) Sand Cuuttenf sack milt/7 gal water SpecsBentoits Patois <br /> Sentonitai20Xsn1lds) { Ated <br /> faduaarSpecSFsc6ds�_9L tvranss SpeesonFBa SPe �^_T <br /> placement Method ped Free Fail Other <br /> seat temptation Compiete ushtaom Gap—ft(p <br /> I HEf"y COW.FY THAT i HAVE pREPARED TM APPLJCATLON AND THAT THE WORK MALL BE DONE IN ACCORDANCE WITH SAN <br /> JOAGWI1 COUNTY ORDINANCM STATE LAWS.AHD RULES AND RSfdUtATIONS. t ALSO CERTIFY THAT MY REQUIRED LICENSE LS <br /> CURRENT XMI ACTIVE WITH THE CALWOIIMra CONTRACTORS STATE LiCENSB BOARD AND THAT 1 AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> NlIUI`M74)�( DV NOTICE REQUIRED t17R WSPECTIONS <br /> TtTT.F DATE T l' <br /> LON7NACTORa SKstUaNR _ v <br /> c� Ght t i- h S m , <br /> 1 <br /> 41 1 <br /> YMENS <br /> coait <br /> � wy� ; <br /> a <br /> EpARTNIEHT USE ONt,-Vgf Area <br /> Appliation Accepted Dale //-I �' <br /> eats Ernployee!W. <br /> Dastrictlan krspection BY <br /> G MkTIT9 7 <br /> w aF U <br /> U 4.. <br /> Amaunt P°r^cul Invoice r! Wnll IDrI <br /> PE SC Received CheckiTr Date $ervlca Ro uusf t1 <br /> Codes Info B Cosh Re"tted p Z <br /> 3 33 0 i5 <br /> WELL MaTTAUCTION PERMIT <br /> £FtD 53OR <br />