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- WELL D&PURUCTION PERMIT116 Co PUBLICWATERSwm -es ONO SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTAIENT 304 E WEBER AVE 3"°FL-STOCKTON CA 95202 -(209)q68- COPY NON-REFUNDABLE PERMITDDCALL(209)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISS JOBARESS Y CITYIZIP j q M CROSS STREET APN PARCEL SIZE AND USE APPLICATION 4 e ONNNER PHONE //'�'I OWNER ADDRESS CITYlSTATRIZIPz&y(d (a 7� 'Y N CONTRACTOR PHONE �' I CONTRACTOR ADDRESS 0TVISTATEJZIP 5 )I C-57 WELL DRILLING LICENSE NUMBER EXPIRATION DATE 231 PERFORATION CONTRACTOR PHONE. _ PERFO TION CONTRACTOR ADDRESS CITYISTATEIZIP 7757 Well Drillingc License Number L:Je Sxpi ration Date-� [� ❑ Bureau of Alcohol,Tobacco and Firearms-Users of Iligh Explosives License Number Expiration Dale ❑ CHP Hazardous Material Transportation for Explosives License Number Expiration Date ❑ San Joaquin County Sheri ff-Coroner Explosives Application and Permit License Dumber Expiration Dale ❑ California Occupational Safe Hcallh-Blaster License Number Expiration Date REASON FOR DFsTRUcriON Dry ❑ Replacement Well ❑ Caved In ❑ Pit Well ❑ Inactive ❑ Test Hole Detected I Suspected Well Water Contaminant(s) Adjacent property with contamination (Address} Known Soil/Water contaminants at adjacent property + ExisTING WELL COINSTRUC'rION DETAILS VOpen Bottom ❑ Gravel Pack ❑ Uneased 0 Other Well Log copy attached 0 Yes ❑ No Grout Seal ❑ No ❑ Yes ft below ground surface(bgs) Hole Diameter inches Well Conductor Casing ❑ Yes ❑ No Depth of Conductor Casing fib s Diameter of Conductor Casing inches Well Cast rig Diameter_�-_Q,____inches Total Depth 1 J21 .11 Depth to Water (t Depth of Casing R bgs DE.STRIICTION SPECIFICATION 7 /� Sealing Material from % fl bgs to [/ R bgs Filler Material from ft bgs to tt bgs Well casing to be perforated by one of the rolluwin methods: from fl bgs to it bgs ❑ Mills Knife Number of cuts every R and/or 0 Explosives ❑ Detonalmg oord ❑ with prujecliles every ft ❑ without projectile O Detonating cord and boosters ❑ with projectiles everyfl ❑ without projectile ❑ Other Sealing Material ❑ Neat Cement(94 Ih hagl5-h gal realer} and Cement ,rack mix/7 gal water entonite Pellets ❑ Bentonite(20%solids) ❑ ufacturer Spec%solids % Name ❑ Specs an File LISpecs Submitted Placement Method 11yumped Free Fall 171 Other k Seal Completion ®/Complete with Mushroom Cap fl bgs ❑ Complete to Existing Surface Pad I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION LAWS. MI UiV1 24 HOUR ANCE NOTICE REQUIRED FOA INSPECTIONS CONTRACTORS SIGNATURE , TiTLt: DATE Y i I ..._ 1 — — PAY BVI ENT ... . .. _F RECEIVED _ DEC-LS-2.008 i SAN JOAQUIN COLIN ENVIRONM RTTAL FALTH DEPA M EIS !Z 3 MIA _ A T M E N T USE O N L Y Application Acccpte Date Area Destruction Inspection By Date Employee IDN COMMENTS 4 i p y a. PE SC Received Chec I Amount Permit) Codes Info B emitted Date [nvoice#i Well 1D# Sery a Re oast# l:lcD aa-oz-oox 1721l20a5 well Desl=io Penni)