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W'..,L DESTRUCTION PERMIT P. If oKKG� 304 E Wt:IR:R Ave . SAN JUAr)UIN CODNI'Y ENV IRONMf:N'1'AI. IIf:AI J'll DEPAR'l'MEN '1' O / �unI,ICWAniRSvs � .ta "' F1.(N N 1 - Sr(K'KI'ON CA 95202 - (209)4611-. 4211 V V PIDFSt 1 VFAR FROM DATE ISSUED NON-REFUNDABLE PERMIT CALL/ (AVY) "J-1071 run n.erc......... -.--- ----- - - -- ! / r1 /q- eer to CITY/ZIP C t JOB ADDRESSLy/��.� �L� !� �r .APA). J -3°I - f 4frL - C/.3 PHONE /4r OWNER �� N ,> CITY/STATEtZIT' / `✓�I�. ems' r/J 4 DwNt:R ADDRESS n / PHONE_ CONTRACTOR (!!2 Q CITY/STATE/ZIP 7ZLt L/OC lL CONTRACTOR ADDRESS ' - UI -6-57 WELL DRILLING LICENSENUMBER 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 ❑ California Occupational Safety Health - Blaster License Number Expiration Date REASON FOR DESTRUCTION ❑ Dry ❑ Replacement Well Caved In ❑ Pit Well ❑ Inactive ❑ Test Hole Detected/Suspected Well Water Contaminant(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 ❑ No Grout Seal ❑ No ❑ Yes ft below ground surface (bgs) Hole Diameter inches Well Conductor Casing ❑ Yes ❑ No Depth of Conductor Casing ft bgs Diameter of Conductor Casin¢ inches Well Casing Diameter inches Total Depth ft Deldw Wat R bgs 1' Depth 62f± -2 DESTRUCTION SPECIFICATION Sealing Material from ft bgs to ft bgs Filler Material from ft bgs to ft bgs Well casing to be perforated by one of the following methods from It bgs to ft bgs , ❑ Mills Knife Number of cuts every ft and / or ❑ Explosives ❑ Detonating cord: ❑ with projectiles every ft ❑ without pmjectile ❑ Detonating cord and boosters: ❑ with projectiles everyft ❑ without projectile ❑ Other Sealing Material ❑ Neat Cement (941b bag/5-6 gat water) ❑ Sand Cement sack mix / 7 gal water ❑ Bentonite Pellets ❑ Bentonite (20% solids) ❑ Manufacturer Spec % solids % Name ❑ Specs on File ❑ Specs Submitted Placement Method ❑ Pumped ❑ Free Fall ❑ Other Seal Completion: ❑ Complete with Mushroom Cap ft bgs Cl 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. MINIMUM 4 _HTO/UR ADVAN E NOTICE REQUIRED FOR INSPECTIONS CONTRACTORS SIGNATURE: JIA Q TITLE: ., DATE 1 t C] `fy caul t Q DEPARTMENT USE ONLY c� Application Accepted By pate O / �l US Destruction Inspection By �// v Date COMMENTS eA - r' f - Trc -S M r I PAYMENT RECEIVED AUG 19 2005 SANI ENVIRONM NTANTY IiPALTH DEPARTMENT Area S 9 Employee ID# �f a ti PE Codes SC Received Info 8 Check#/ Amount Date Permit/ as Remitted Service Request # Invoice# Well ID# 143.7 /4r Zd 1Sn-rA> 0 � Gip 45&0 END 41 -02 -MM N7,04 Well DeAnw6On Permil Addendum 4A Ic &N.04