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ALL DESTRUCTION PERMIT" 99 PDBLIC WA'I�itS No SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304E WEBER AVE 340 FL-STOCKTON CA 95202 - (209)468-$420 NON-REFUND E PERMIT { / CALL( 09 9 -7697 FOR INSPECTIONS EXPIRES 1 XEAR FROM DATE ISSUED I_1VVfr1'0W0V #7L9,( y JOB ADDRESSOra [a I I CITY/ZIP CROSS STREE j APNZd"15f) PARCEL SIZED Y D L D US PPLICATION# � f�C../ PNONE ��- -1129 w OWNER nay /'� /� OWNER ADDRE /'/ //�3132 49 - CITY/STATE/ZI -IUN_f_A / U y CONTRACTO ) // l Unt" PHONE 7�-/�7 793,x... "� q COR ADDRE �56 - /L) l ` CITY/STATE/ZIP PC-57 WELL DRILLING LICENSENUMBER YOK/2ily EXPIRATION DATE PERFORATION CONTRACTOR PHONE PERFORATION CONTRACTOR ADDRESS CITY/STATE/ZIP ❑ C-57 Well Drilling License Number Expiration Date ❑ Bureau of Alcohol,Tobacco and Firearms-Users of High Explosives License Number Expiration Date ❑ CHP Hazardous Material Transportation for Explosives License Number Expiration Date ❑ San Joaquin County Sheriff-Coroner Explosives Application and Permit License Number Expiration Date 91) ❑ California Occupational Safety Health-Blaster License Number Expiration Date REASON POR DESTRUCTION ❑ Dry ❑ Replacement Well ❑ Caved In ❑ Pit Well ❑ Inactive ❑ Test Hole Detected/Suspected Well Water Contaminant(s) S_ Adjacent property with contamination (Address) Known Soil/Water contaminants at adjacent property EXISTING WELL CONSTRUCTION DETAILS ❑ Open Bottom Gravel Pack ❑ Uncased ❑ Other Well Log copy attached ❑ Yes I-9 No Grout Seal ❑ No ❑ Yes ft below ground surface(bgs) Hale Diameter inches Well Conductor Casing ❑ Yes fi)<o Depth of Conductor Casing ft bgs Diameter of Conductor Casing inches Well Casing Diameter inches Total Depth(/AI/L{r Depth to Water �ZO ft Depth of Casing it bgs DESTRUCTION SPECIFICATION r r Sealing Material from �'k ft bgs to__76n�ft bgs Filler Material/e,3 SM.��Gr from sV it bgs to 6 ft bgs Well casing to be perforated by one of the following methods: from ft bgs to ft bgs ❑ Mills Knife Number of cuts every ft and/or ❑ Explosives ❑ Detonating cord ❑ with projectiles every ft ❑ without projectile ❑ Detonating cord and boosters ❑ with projectiles every ft ❑ without projectile ❑ Other Sealing Material ❑ Neat Cement(941b bag/5-6 gal water) Sand Cement �� sock mix/7 gal water ❑ Bentonite Pellets ❑ Bentonite(20%"s) ❑ Manufacturer Spec%solids % Name ❑ Specs on File ❑ Specs Submitted Placement Method � �ped ❑ Free Fall ❑ Other Seal Completion kl ..plete with Mushroom Cap G ft bgs ❑ Complete to Existing Surface Pad I HEREBY CERTIFY THAT 1 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. I ApIV NCE NOTICE REQUIRED F INSPECTIONS CONTRACTORS SICNATU TITL ' DATE I I - — L, I NOUS � {--i—�- �• f --,— —1-- — --I—' Ell PAYMENT '— --RECEIVED __' I'll2 6 2005 SAN JOQUlN NTATY HeAgM DEPARTMENT DEPARTM EN USE ONLY �� i Application Accepted By Date 1� Area „'Vew D ly Destruction Inspection�B,y� —+*" Date a Employee ID# C 1 COMMENTS / —0 -��'S - GlL/. �Ctsc tiGJ�_=•� `lJtr2 -lei°cS� - ,1 �r,f�i '7>GF ij Cf)T pFr CRS/nJr PE SC Received By/.) Amount ate Permit/ Invoice# We111I1# Codes Info ash Remitted Service Reguest# EHD 43-02-008 W,11 Da o.n Pvmit 1=005