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WELL DESTRUCTION PERMIT <br /> PUBLIC WATER SYS7E iys ❑Nc <br /> SAN JOAOUIN COUNTY EWIRONME WAL HEALTH DEPARTMENT NO E MAIN STREET-STOCKTON CA 95202 - (209)469.3420 <br /> NON-REFUNDABLE PERMIT CALL(2091953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOe ADURE53 /). erg2 CmaIP <br /> CROW STREET , N 1 '�O• PARCEL SUM__LAND(U9SE APPLICATION 0 - <br /> OWNEA Pitch. <br /> OWNER ADDRESS 57 CITYISTATE21P <br /> CONTRACTOR I poosE "1-3Z <br /> CONTttACTOrr ADDRESS �T' 1,1 ��//tel G/�-� CITY/STATE/LP <br /> �'1 F57 WEu DRLLIWD L ENSE NUMSERQ EI(MRATON DATE <br /> PE/RFORRATION CONTRACTOR I I PHONE <br /> PFRFORATION COtilnus OR ADDRESS CITY/STATEILIP T1 P. !� HY✓I <br /> ❑ C-57 Well Drilling License Number Expiration Date <br /> ❑ Bureau of Alco ld,Tobaom and Firearms-Users Of High Explosives License Number Expiration Data <br /> ❑ CNP HaTardous Material Transportation for Explosives License Number Expiration Date <br /> ❑ San Joel County Sheriff-Coroner Explosives Applloatbn and Permit License Number Expiration Data <br /> ❑ California Occupational Safety Health-Blaster Lkense Number Expiration Dale <br /> Re.uo1 Fw DeaneucnoM ❑ Dry XL11Replacennent Well ❑ Caved In ❑ Plt Wall O trrctive ❑ Test Hole <br /> Detected/Suspedad WSII Water Contaml aant(s) <br /> Adjacent property vith contamination(Address) <br /> Knc i n SoitWater contaminants at adjacent property <br /> EXISTING WELL CONSTRUCTION DETAILS ❑ Open BdlClll J✓GfdYll Pall ❑ Uncalled ❑ ONer \. <br /> WNILogoopyattacheu ❑ Yes ❑ No Grout Seal ❑ No ❑ Yes_ftbebW9roundsurface(bgs) Hob Diameter hldre V <br /> Well Condattv CaslnB❑ es ❑ No DaPth d Contlupor Caebp fiege Dbnati r of Conductor Caaln9 Inches (A <br /> Wall <br /> Client,Damsel--_ — indrs Total Depth it IMWh W Wats R Depth of Casing Rugs "hi <br /> DESTRUCTKIM SPEC 11CAT10N <br /> Sealing Material from�fi bg%b L Rings Fllla Mvelrtal- from t1 DMs to Rope <br /> Well wing tow derforated by tHr of the follovdnd methods: V JAM <br /> from 1�� a f30►�jYeos <br /> ❑ Mills Knife Number of cuts every andhor <br /> >11"ExplosNeal Detonating mrd E3Wih projectiles every R Wtghaut projectile <br /> ❑ Detonatng oord and boosters ❑ vilth pmjectles every ft ❑ WiUwut projectile <br /> ❑ Durr <br /> Sealinglihide l ❑ N@KCemem(941bba9/5-696IWateh0 Sand CMnent �fr Ti aeG mG/7 Dal svakr ❑ Bentonite PaReb Q0 <br /> I.: Bentonite(20%sonde) = Manufacturer Spec%seeds_% Name ❑ meson ie, capers Submitted p� <br /> Placement Method D Pumped C Free Fall / ❑ OVrf \• <br /> Seal Completion Complete vriN Mushroom Cap 3 R Dgs ❑ Complete o Existing SurfI 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. 1 ALSO CERTIFY THAT MY REQUIRED LICENSE 18 <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> R VANCE NOTICE REQUIRED FOR INSPECTIONS <br /> r CONTRACTORS SIGN71ATURE <br /> RAY <br /> + ♦ t CAVE <br /> . -� -L L _ - -t <br /> RE <br /> t /I(� 44 <br /> *� LCA— _ FmAa Ec <br /> r X57 0 . + <br /> + � 1 r • r _ E <br /> QJ <br /> - T7r* -+- —: <br /> DE PA'R T/MENT USE ONL `tJ <br /> Area <br /> I /iA >'L../ �!a/!!� <br /> I'Applicaban A[oep _ Dale <br /> '1 Deshuction Inspection By Date 4J Enployae IDk__ ; <br /> COMMENTS _ <br /> PE Sc Race Wed _ Amount PermlV InvolgR Wag IDR <br /> Cads IrHo a Ge Ramftbd Data S., eR tlpeta <br /> Codes n 93 o SQL+O O DD <br />