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WELL DESTRuc"I'ION PERMIT <br /> '""'-"""'-�"-""`-'•"^^"�^•^.' 1868 East Hazelton Avenue-STOCKTON CA 95206-6232-(209)468.3420 <br /> NON-REFUNDABLE PERMIT CALL 2?O1 95?.'W'FOR IN3-- - EXPIRES EXPIRES 1 YEAR FROM DATE ISSUED <br /> Joe ADDRESSS��iC� l�j -r !&a c Y'c%m e n 4-r c"/zp_ A ca f,\ <br /> CROSS STREET-F?]} 'C C`r f<IU. APH iiL4 - u41-3;(-V PARCELstzE -7LANo USE <br /> APPLICATION o <br /> OWNER ,,�p�{� 3 PHON'c <br /> OWNERADDRE99 �lMi CITY/STA7EIIJP <br /> CONTRACTOR (� /-� �`�� PHONE 7 i)1 u;?-7-7q <br /> CONTRACTOR ADDRESS_[-.t/ 1�(1 4 CITY/STATE77JP ('-C,1�.• C A <br /> /,,- C-57 WELL DRILLING LICENSE NUMBER .2-/�' 3 EXPIRATION DATE -7-_I�(/`` <br /> PERFORATION CONTRACTOR 1 -j. , II A (PHONE <br /> PERFORATION CONTRACTOR ADDRESS CITY/STATEZP I -I �� A 2 2 L� <br /> ❑ C-57 Well Drilling License Number �T <br /> Expiration Date <br /> Bureau of Alcohol,Tobacco and Firearms-Users of High Explosives License Number Expiration Date <br /> CHP Hazardous Material Transportation for Explosives License Number Expiratidn Date <br /> San Joaquin County Sheriff-Coroner Explosives Application and Permit License Number Expiration Date <br /> CalifOmia Occupational Safety Health-Blaster License Number Expiration Date <br /> REASON FOR DESTRUCTION Dry ❑ Replacement Well ❑ Caved In ❑ Pit Well ❑ Inactive ❑ Test Hole i <br /> Detected/Suspected Well Water Contaminants) <br /> Adjacent property with contamination(Address) <br /> Known Soil/Water contaminants at adjacent property <br /> EXISTING WELL CONSTRUCTION DETAILS Open Bottom )4,Gravel Pack ❑ <br /> Uncasetl ❑ Other <br /> ��s— � <br /> Well Log copy attached ❑ Yes %P No Grout Seal ❑ No I7.Yes NIA R below ground surface(bgs) Hole Diameter 7 Irmhes <br /> Well Conductor Casing vas '¢� No Depth of Conductor Casing itbgs Diameter of Conductor Casing inches <br /> Well Casing Diameter'---S—inches Total Depth SG R Depth to Water V,D R Depth of Casing R bgs <br /> DF.SfRI(TIONSPECIFICATT OV CI <br /> Sealing Material from 17..E R bgs to 0 R bgs Filler Materialu .-from_�.i—' R tgs to Q A bgs <br /> Well casing to be Perforated by one of the following methods: from R bgs to R bgs <br /> ❑ Mills Knife _Number of cuts every R and/or <br /> JtJ Explosiv hnTgod ❑ ❑ without projectile <br /> Detonating card and boosters EJ with projecti <br /> 13 Other les every___n ❑ Without projectile <br /> Sealing Material Neat Cement(941b bag/5.6 gal water) Sand Cement ,?j_Sack mix/7 gal water Xentonite Pellets <br /> Bentonite(20%solids) Manufacturer Spec%solids_% Name Specs on File / ece Submitted <br /> Placement Method ,X Pumped Free Fall Other <br /> Seal Completion Complete with Mushroom Cap C R bgs x Complete to Existing Surface Pad <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS i <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> CONTRACTORS SIGNATURE e��GI /1'�tr✓��� TITLE �C <br /> I♦ , �t-C�� L�•-. '.4 <br /> y DATE <br /> PAS <br /> SVT' <br /> JUN <br /> I SqM� ? 2of� <br /> Oq <br /> 1 M�CrElvyo°pq�,yrq�N� <br /> i TMFNT <br /> DE P M E�N USE ONLY <br /> Application Accepted By Dale area <br /> Destruction. <br /> Date Employee ID# -� <br /> COMMENTS <br /> PE SC Received Check#/ Amount PermiU <br /> Codes Ifo ash emitted Date rvlce a est# Invoice III WeII ID# <br /> -ed 411 Alla '�7�T`,YTL- ^- 1 \ WELL DESTRUCTION PERMIT <br />