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('WELL DESTRUCTION PERMIT yt 'v, p <br /> PUBI] Yea Da No <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE 3`"FLOOR-STOCKTON CA 95M-C209))44`69-420 <br /> NON-REFUNDABLE PERMIT CALL(209)953-7697 FOR INsPwfiONS EXPIRES I YEAR FROM DATE ISSUED <br /> JOB ADDRESS 26639 E. JONES RD -41v,-47- iCD ClTvri�� E� 20 <br /> AL0N 953 � <br /> l y,7 <br /> OWNER ROCHE.--RR05- "` PHONE 601-5300 <br /> OWNERADDRESS 26639 E. JONES RD, CrTY1STATrmP—ESCALON. CA 95320 , <br /> CONTRACTOR HENNINGS BROS. DRILLING CO., TIBC. PHONE 545-1185 <br /> CONTRACrORADDRESS 3525 PELANDALE AVE. CITYlsTA'TuzIPMODESTU.CA 95356 <br /> QQ C-57WELLDMLLINC LICENSENUMB£R 290813 EXPIRATION DATE 5-31-06 <br /> PERFORATION CONTRACTOR PHONE <br /> PERFORATION CONTRACTOR ADDRESS CITYISTATFf4iP <br /> 0C-57 Well Drilling License Number 290813 Expiration Date 5-31-06 <br /> ❑ Bureau of Alcehol,Tobacco and Firearms-Users of High Explosives License Number Expiration Date <br /> ❑ CHP Hazardous MarcTial Transportation for Explosives license Number Expiration Date <br /> ❑ San Joaquin County Sheriff-Coroner Explosives Application and Permit License Number Expiration Date <br /> ❑ California Occupational Safety Health-Blaster License Number Expiration Date. <br /> REASON FOR DU MUCTION ❑ DrY [2 Replacement Well ❑ Caved In ❑ Pit well inactive 0 Test HD[c <br /> Detected J Suspected Well Water Contaminaat(s): <br /> Adjacent property with contamination(Address): <br /> Known Soil 1 Water contaminants at adjacent property ''11 rrf� <br /> EXISTING WELL CONMMVCTION DETAILS ❑ Open Bottom 13 Gravel Pack ❑ Uncased [3Other--_P_U_MP IN WELL � <br /> Well Log copy attached ❑ Yes d No Grout Seal ❑ No ❑ Yes ft below ground surface(bgs) Hole Diameter inches S <br /> Well Conductor Casing 13 Yes ❑ No Depth of Conductor Caging ft bgs Diameter of Conductor Casing inches too <br /> Well Casing Diameter inches Total Depth 7 ft Depth to Water R Depth of Casing ft bgs 7 <br /> DESTRUCTION SPECIPICATION <br /> Sealing Material from 0 it bgs to 2 ftbp Filler Material 2 from b o tt 0 m ft bgs to n bgs ' <br /> Welt casing to be ftdU§tSA,hy 000ne of the foliowln2 methods from ft bgs to It bgs <br /> ❑ Mills Knife Number ofcuts every—ft and Ior r <br /> ❑ Explosives ❑ Detonatin3cord: ❑ With pmjectilesevery it ❑ withoutprojcctiie <br /> ❑ Detonating cord and boosters: Q with projectiles everyft ❑ without projectile (1t <br /> ❑ Other (,71 V) <br /> Sealing Material [3Neat Cement(941b bag 1 S-d gd venter) x7 Sand Cement 6 sack mir17 gal water idgeo ❑ Ilentonite PeDets <br /> M Bealoalte(20%solids) Cl Manufacturer Spec Y solids % Name ❑ Specs on File 0 Specs Submitted e <br /> Placement Method +=Pumped ❑ Fra Fall ❑ Other I N S I D E <br /> Seal Completion: ❑ Complete with Mushroom Cap ft bgs 1( Complete io Existing Surface PadP UM PH OUSE <br /> 1 HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> ,IOAQVIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> ~as eeRAEiPi-A1vD._ACTIVE WITH"Ff�E-CAL FPORNIA-e@N`FlbkMR D-'7'rfA_'F$*M-W-e0MP1;1ANCE WfTIt-ALL <br /> WORKERS COMPENSATION LAWS. <br /> MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br /> CONTRACTORS SIGNATUR . l LHO SUP ERVIOSR -- DAT ..1 Q-0 5 <br /> h - P <br /> 4Lf <br /> rtTEAZTF�DE PARM <br /> 1 I PARTMENT USE ONLY c� <br /> Application Arcmted By _14NDate Sr1O_r ' :Area <br /> Destruction Inspection By Date�/�� SIJ—� Employee IDN PoC7 <br /> COMMENT'S + <br /> PE SC Received Amount Date Permktl Invoice# well IDN <br /> Cada Info 'By Cash Remitted Service R 'nest# <br /> 43.-r- rb! lZi q 01, 2Od <br /> ERD 43-02-M Well Dpoud o.ftT d MOW=4504 k fnx.04 <br /> 6rmt <br /> f <br />