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llOa <br /> WELL DESTRUCTION PERMIT <br /> PUBWC WATERSI'S[EM❑Ym 1661' <br /> SAN JOAQUIN COUNTY ENVIRONMCNrAL HEALTH BEPARTMENT 304E WGER AVE 3"PL-STMaTom CA 95301 -(209)46"20 <br /> NON REFUNDABLE PERMIT /r CALL(209)953-7697 FOR INSPECTIONS EXPIRES I YEAR FROM DATE ISSUED <br /> JOE ADDRESS ( 1 _'S'` clrrizlP I ls3 <br /> yy�j o <br /> CRIXS S'EREET PN,�(�:�f" <br /> 2 iO- DI PARCLLSIZE`�r- ?Nn USE PRICwTIONN Q <br /> ®� n <br /> OWNER YO oxe <br /> OWNERADDRE4S IJZ IOZr / a' <br /> I rtr/$1'ATPJZIP <br /> CONTRAC R �/I n I 1 PHONE <br /> CO/M�RAROR ACHIM% l i ff Y� -ILeNC / o -y CHY(STATFJT.IP 442 zX, <br /> ( S1 C-57 WELL DRILLING LICENSENUMEER 7 E%PIRATxH!DATE �J <br /> PERFORATION CONTRACTUR PHONE <br /> PERMRATION CONTRACTOR ADDRESS CITV/STATFIZIP <br /> ❑ C-57 Well Drilling License Number Expindon Dares <br /> ❑ BU.OfAlcohol,Tobacco and Firearms-Users of High Explosives License Number Expiration Dab <br /> ❑ CHP Haea does Material Transportation fur Explosives License Nu mher Expiration Dab <br /> ❑ San)oaquin Courcy Sheriff-Coroner Explosives Applicrdon and Permit Limnse Number Expiration Dab <br /> ❑ Cdifomu Occupational Safety Health-Slaver License Nmober Salutation Dab <br /> REASON FOR DESTRUCTION ❑ Dry eplscamwnl Well ❑ Ca ed in ❑ PIf WNI Q leaatwo ❑ Teat Hole <br /> Dtecbd/S.x ted Well Water Conbmivavl(a) <br /> Adjacemproperty Mtheontaminsdon(Address) <br /> Known Soil/Wabreanramirmnb at adjacnt properry <br /> F,.u.NG WeLL Consrxu.(W DEEAI0 ❑ Open Hotrom Par101avei Pack ❑ Uncaead ❑ Or. <br /> Well Log mpy.mchM ❑ You KNo Grout Saar ❑ No ❑ Ya_flbelawgroundsulfacc(bgs) Hole Dlalnaterinches ` ' <br /> Well Conductor Caring ❑ Y. ❑ No Depth of Conductur Caring Bbtt Diameter of Conductor Casing inch. )V <br /> Well Casing Diameter inch. Total Depth._(,42__It Depth W W'ater_.2je R Depth of B bgs NC <br /> DGTTRUCTION SPECIFICATION <br /> Sealing Material from ft la flbp Filler Material from flbpm Itblp V� <br /> WeH.ring to be rp,rff at,at p by one oethe fallowlo,methods: from E bgs to fl by <br /> ❑ MHIa Knife NumberofeuDnery _fl and/tar_ <br /> ❑ Eapmst,ms ❑ Delonrting cord ❑ wnhpmjemilescmry fl ❑ wimmutpmjecdle n <br /> ❑ Demnetmg mrd and boasters ❑ wirh pmj miles everyfl ❑ without projaNle <br /> ❑ Other <br /> Scaling Material ❑ Neal Cemenl(94fh Mg/5-6gof wkr) ❑ Saad Cement sockmis/7galmvr iIevMNte Few. <br /> ❑ Bentonite(2O%mllda) Cl Manufamuer Spa%solids_% Nome ❑ Specson File ❑ Specs Submitted <br /> Placement Method❑ Pumped ❑ Free Fall ❑ Other n <br /> Sed compktion A Complete with Musbroom Cap t bgs ❑ Complete m Exirtleg Serrate Pad I 1 <br /> E Cyi <br /> 1 HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT TNT E WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND RECULATIO.NS. 1 ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT 1 AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS <br /> MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br /> //xI r <br /> COMMCTORssu"NATURE V L f/ ///L/ti�J'T TRLE-9l w f /(C If DAT[ 7f�1/6 <br /> N <br /> I�fy (LDwIlk <br /> PAYMENT <br /> RECEIVED <br /> JAN 2 2 2006 a <br /> b <br /> SAN JOAQUIN COUNTY @� <br /> ENVIRONMENTAL V <br /> HEALTH DEPARTMENT p,;de woy <br /> DEPARTMENT USE ONL - ✓�� <br /> Appli.d.Acc BY Dara 2. D$ A. <br /> Destruction lmFeaton By -6- - Dae YY%. Employcc IDN <br /> COMMENTS— <br /> � <br /> I <br /> PE SC Hemmed CM1ec Amount Permit/ <br /> Coon Info B Ad.ue.," D.te serd.H N IvvorRaN WNI IDN <br /> fi23 ltnl AY33.D Js .cIto g� <br /> ex.w . seal Ovm .road <br /> IR]/l.5 <br />