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WELL DESTRUCTION PERMIT <br /> I PWW WATER SYS1E1yt []Yes.fil N o <br /> SAN JOAatrsi CouNtT EaryyiONtiFNTAL t141MLTH DE?ARTMr]YT SM E MMPJ 3,RWI-STOCKION CA SM2-Imo)498-8420 <br /> NON-REFUNDABLE PERMIT CALL 209 963-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM OATS ISSUED w <br /> JoeAoOREae 18667 Jacob Brack Road CmmP Lo�d,,�i95x42 <br /> �-Ca. � <br /> CRMSMEET_W- Turner Road JaPN - PARCELSIt�� IMEAPPIIcaTiani <br /> Sutter Home r In,.. 9707)963-3104 <br /> ONNEIL—OWNERADI)RESS P.O. Sox 248 CfrOSTATd7DP St. Helena Ca. 94574 <br /> CONTRAcraR Ld a Chriaj:eAsen - _PHate - 9U9 394-2833 2' <br /> CONtRAOTwtADbREss 11001 Etiwanda Aue CmfSTAtEILP Fontana �a. 92337 <br /> C47WELL DRe.1m IICENSeNUMSE]i 510011 F�cnRitTreNDATa: 10-Z-05 <br /> PEAPORATraNCotl7ftacTOR N/A _ PNcrE <br /> PEiPORAYIONCONTRACTMAO3RCdt7N/A _ CIrv1511nTrJZr _ I <br /> 13 C-ST Well Dniling License Number Expiration Date + <br /> BUI'eW of Alcohol,Tobacco and Firearms-users of High Explosives License Numh-W Expiration Date i <br /> CHP kimordous Material Transportation Por Explosives License Number E pbation Oar <br /> San Joaquin County Sheriff-Coroner Explosives Application and Pam* Llcense Number Expiration Date <br /> Caldornle Ocaipalioriat Safety Heallh-91ealm license Nuober Expiration Date <br /> iie.■ownewy"mu mors O Dry O Replacement VM1 0 Caved In [3 PR Well O loscim a Test Hole <br /> Detected 1 Suspected Well Water Contaminaettje - <br /> Adjacent PropertywithcOntaminatlm(Addmw - _ <br /> Known$oil!Waiereoa4minants at adjacent Properly <br /> EXismeo WELLCONE7Hi�71ON DEr/Urs 0 Open eoham O Gravel Patic D l3ricased d Other <br /> Well Log copy oM hod L3 Yea D No Omni Saab 0 No 13 Yes ft below ground a mfac6 gips) Hole Diameter Infixes <br /> Wen C,onduetor Caefiq O Yea D No Depth of CoRduetor Gestrig -R bgs Dlarneler 0 Conductor casing inct*s' <br /> Wall Caving Du emr ind+ea Total Depth R bMh to Waor R Depth dCeahtp n ugs <br /> if-mom St1Gj2rAT1 <br /> ScalingM■torial Rom 600 Rbgsto 0 hogs Fl4erMeblal Rom_ft bgs te_f!bgs <br /> Well cashW to be perftotld by gno of th FollowhM methods- hOm '-n bgs to R bgs Jar <br /> 0 IIIIMa Knits Number of outs every g and I or 12{J <br /> D Explosives CI Detonating cord R Vm pnAecties every R D rntmt projectile W <br /> o Detonating mrd and boasWm D with projectllos everyR 13 WM101A Projeeoa- <br /> O fldie <br /> .Sealing Mobrial Neat Cement(941b Avg/b-6 g8f water) Send Cement SaClt AW 17 gal water BeMoiins Polots <br /> Bentonits(29%solidsl Manufacturer Spec%'so8ds R.L% Name Baroid Spam on File specs subn*ted <br /> Placement 11I PuropedX - Free Fell Other <br /> Seal Commutin CamPlats with Mushroom Cap R bgs Contplele to FxWdng Sumfaee Pad X <br /> 1 HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE-WITIH SAN <br /> JOACiUFN COUNTY ORDINARCES.STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT AND.ACTNE WITH THE.CALIFORNIA WNTRACTORS STATE LICENSE BOARD AND THAT i ARI IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> I IAl!lIfHO. =AE)VANE E REQUIRED FOR INSPECTIONS �1 <br /> CoaTwicToaa SioNATUR <br /> //�!�!// T General t+aaAger MTE 5-1-09 <br /> t I Ieco <br /> 5 <br /> J ID <br /> _ P E <br /> y. !R[919AN! NT1r <br /> -DEp E <br /> Tur.e o d NT <br /> 41 <br /> DE to T USE OH L /J <br /> Application Accepted DelveY cArf Area (/LJ <br /> i Dealructfarr InspaWan B <br /> Deft Employee M# <br /> i COMMENTSXC <br /> uj - <br /> [rc . .v 4-r <br /> 'vZI Cs3 S <br /> PE SG 1ZecoWad Che ArrioaiN POmrIH Involes/ Well IDS <br /> . edea - bit BV •Service mmmesila <br /> jWELL DESTRUCTION KRWT <br /> 7 <br /> r7�L � ,�7r. :�l��l�Yl rJ�✓�83I-�`FS ""BSB;d2,c -45kfs , rr?a?-sz s 9ps� <br />