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WELL DESTRUCTION PERMIT <br /> rlC1i�[, � �--2 PUBLicwAlEASYSTEMM�109)168-1111 <br /> ?5-7_ ��0 t <br /> ' SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPAR T 304 E WEIIER AVE 3-FLOOR-SfOCI(TON CA 9520 <br /> NON-REFUNDABLE PERMIT CALL(209)453-76 7 FOR INSPECTIONS EXPIRES I YEAR FROM DATE IStiUED � <br /> ' CrlYI2I 't/l G�iQ- <br /> 67 <br /> 109 ADDRESS F > <br /> g A <br /> QWNEA i�'� f PHONE 6 d <br /> ON'T£R ADDRESS CMNTA'I'TJZ1P! <br /> CONTRACTOR G / PHONE <br /> CONTRACTOR ADpR1- T CFTWSTATPIZIP <br /> C-57 WELL DRILLING LICENSE NUMBER E%PiRAT10N DATE <br /> PERFORATION CONTRACTOR PHONE <br /> PERFORATION CONTRACTOR ADDRESS CITV;STATFJZIP <br /> ❑ C•57 Well Drilling LicenstNumber Expiration Date <br /> ❑ Bureau of Alcohol,Tobacco and Firearms-Users of High Explosives License Number Expiration Date <br /> ❑ CHP Ha2ardcus Material Transprutation for Explosives License Number Expiration Date <br /> ❑ San Joaquin CCunty Sheriff•COtoncr Explosives Application and Permit License Number Expiration Date <br /> (7 Ceiitomta C]rcupational Safety keakh•8laster License Number Expiration Date <br />+I RFASON FORDEs1'RUCTION I❑ Dry ❑ Replacement Well 5<Cavcd In ❑ Pi Well I❑ Inactive ❑ Test Hole <br /> I Detected J Suspected Well Water Contaminent(s): <br /> Ad)acent praptrty with eonratniaattop(Address): <br /> Kpown Soil l Water contaminants at adjacent property: <br /> t <br /> Extsnxe wRLL CONSTRUCTION DCTAt[S ❑ Open l3ouom Grastl Patk ❑ Uncascd 0 Other <br /> No Grout Seat ❑ No ❑ Yes t1below ground surface(hgs) Hale Diameter inches <br /> Welt Log copy attached ❑ Yes � <br /> Well Conducter Casing ❑ Yes M No Depth or Conductor Gating ft bgs Diameter at Conductor Casino _inches <br /> Well Casing Diameter inches TaW Depth It Depth to Water ft Depth of Cosine _ _1)bgs {tl <br /> D£STROCTION SPECIFICATION V <br /> Sea'IngMattrial from_,' _ftbgsM Abgs Filler Material From fibgsto 1""togs .� <br /> Well using to be perforutcaby ono of the foliowing-methods from—A bgs to R bgs <br /> Q MillsKnlfe NumberoFcutacvery Randior <br /> 13 Explosives 0 Detonating cord: ❑ with pro}eeGles every it 173 without projectile <br /> ❑ Detonating cord and boosters: F] withprojectilesevery ft ❑ withoutpmjectile <br /> ❑ Other <br /> Sealing Material ❑ Neat Cemrns(44 1h bagl S-6 bmf water) ❑ Sand Cement sack mix 17 gal water ArIB."Ittolte Pellets <br /> ❑ Bentonile(20%solids) ❑ Manufacturer Spec%solids �o Name ❑ Specs on File ❑ Spats Submitted <br /> Placement Method ❑ Pumped ❑ Free Fall ❑ Other <br /> It Seel Completlon: ❑ Complete with Mushroom Cap ft bgs ❑ Complete to Esisclog Surface 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. r ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT AND ACTIVE WITH THE CALIPORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS/f <br /> CONTRACTORS SIGNATURE: TITLE: r t DATE' <br /> < 1Q p1 t}J S�YINKY F <br /> �. -' Wi r ++ r .' ,nal• i .s r- ,Hn Rk ,,,,.- ... a r m ESZ <br /> DEPARTMENT USE ONLY � �) <br /> Application Accepted By Dale_jI`29 _ AreaV" . <br /> 1. ... a „ ,t . �. <br /> :�--fhstructinn inspcctidn Fay Date _ .•a,,.....r..•-, <br /> .. l <br /> rµ <br /> 9p9G>1�'��Sa.•.r�'c -;...ecsr.`�.a�:srs�w+n-.�. �., .. .�eu.w. �,,,;•-:--..�..�. <br /> dr:=uVar�+a+ �1Y1i <br /> I PESC Received ChecktN Amount Date Permitr lm-1110 Well III <br /> Codes Info as Remitted Setwlce A ueat# <br /> ENP 9]-pj-OQR Wcn neL id F, n AO ,&.m 411aa 1c 6I 104 <br /> r,r:an <br />