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WELL DESTRUCTION PERMIT <br /> SANJOAQUIN COt1NTV ENWRONMENTAL HEALTH DEPARTMENT 304 WEJIER AVS-fflN <br /> NON-REFUNDABLE PERMIT CALL 21)9 953-7697 FOR INsPruTI sA EXPIRES 1 YEAR FRoM DATE TISSUED <br /> JOHADDRT85 I T C1TYMP p <br /> CRosa STREET V� PA EL SIZE a ND USE APrLiV-AnoN# <br /> OWNER ---,erg PRONE /' <br /> OWMMADDR K 1 C1TY15rATLMp /v _ <br /> CONTRACTOR PHONE N <br /> CONTRACTOR AD110— n 4U if CITYISTATE/7/P s 1 <br /> LAi C47 WELL DRFLLING LICENsEN11MBER EXPIRATION DATE <br /> PERFORATION COYT'RwCMIX PRONE <br /> PERFORATION CONTRACTOR ADDRES4 CITYfSTATEMP ' <br /> 0 C-57 Well frilling License Number F�pirslioe Date <br /> 0 Bureau of Alcohol,Tobacco and Firearms-Users or High Explosives License Number Expiration Date <br /> 0 -CHP Hazardous Material Transportation for Explosives License Number�... Expiration Date <br /> 0 San Joraptin County Sheriff-Corona Explosivm Application and Permit License Number Expiration Date _\[ <br /> 0 California Occupational Safety Halth-Blaster License Number Expiration Date <br /> REASON BOR DFSTRUMM ry 0 Replacement Well 1] Caved in 0 Pit Well laaetive E3 Test Hole <br /> Detected I Suspected Well Water Conlaminaot(sl - <br /> Adjacent properly with contamination(Addressl - R <br /> Known Soil I Watermntaminants at adjacmt prapexty <br /> EXISTING WPJA.CON$rRWT1ON DETAILS 0 Open Barium O (travel Pact 0 Uncared ❑ other �y <br /> Wee IAS copy attached 0 Yes Q No Groot Smi ❑ No 0 Yes ft below ground surface(bgs) Hale Diameter inches 1 <br /> Wee Conductor Castne 0 Yea 0 No Depth of Conduc�t�l�CIasing ft bas `y�Diemeler of Conductor Casing . inches <br /> Wen Crslag Dialmeter N inches Tolal Depth�L_R Depth to Water -, Depth of CzAnE ft b® <br /> dFSITt17C_I'ION-SPEci wAT1ow <br /> Sealing Material from fl bge to ft bgs Finer Materlai from R bas to fl bgs <br /> Well casing to be perforated by one of the Iothmirte methods: from ft bgs to R bgs <br /> ❑ MnlsKalfe Nurttberofcvduvery Rand/or <br /> O Explosives C Oma-ling eord 0 with projxtiks every ft i] without projectile <br /> 0 Detonatiag Cord and boasters 0 with projectiles every R 0 without projcetile <br /> ❑ Othn <br /> Reeling Material 0 Neat Cement(94 th bag 15-6 gal%vier) 0 Sand Cement ane*mix 17 gal water Benraadte Felled <br /> 0 Bealaudte(20%solldt) O Manufacturer Spa%aolids % Name O Specs an File 0 Specs Submimed <br /> Phrcement Method❑ Pumped e*Free Fall ❑ Other �'�!]VEZ <br /> Seal Compietlon 0 Complete with Mushroom Cap ft bgs Complex to I:silting Surface Pad <br /> 1 HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE 1N ACCORDANCE WITH SAN <br /> JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS. 1 ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> 4=;;;;:IC£REQUIRED FOR INSPECTi IONS <br /> CON TTewcmaes Stctvwt TrrLE DATE Z <br /> ffft 11 4—L 4- <br /> Q •�qi •t W�- -t•f- �.-�I��'�-.-.R�..,��/.kms_-E--���r-'f--�, `—t--I--t-� �-T. .�.. <br /> .'/ L — - <br /> WAY 2 4,20to LI <br /> -t-T.._..t �.. � � _ _s SAN. - <br /> _.4,--�_ .r-�... .r_ _,+•---•--- -.fiJ. E7WIAFtQN11NEfITNTY <br /> HEALTH DEPARTMENT <br /> . <br /> . _I , <br /> D,£P <br /> TM-E-N, -LS£aONA ,yam <br /> AVIkadon Accepted y Dere 7i 01 Ara _ 49 <br /> Dcstluction Inspection Date 5 /O Employee IDN <br /> COMMENTS_ - .s 6 .¢t/ j[ }` !YX/2- <br /> r <br /> SC Retetvald hecldl Amount Permit/ <br /> Info B III YentttaM Date Service R mesa# Invoices• Wei 1E34 i <br /> 3 '2 <br /> tAiDa Wglppryytljpa Ptnod ' <br /> too , <br />