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WELL DESTRUCTION PERMIT " �! <br /> PUBLIC WATEBSYffEm ❑Ya❑No <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 301E WEBER Ave 3"FL-STOCRTON CA 95202-(209)4663420 <br /> NON-REFUNDABLE PERMIT CALL(2 9)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOBxmIxpARDRES$ L- [A CITYJZIP j(('aCL Oaf <br /> y <br /> CROSS SERER APN PARCELS ✓r' LAN USE A[PP1/{CATI/ON X)� <br /> OWNea PHONE /Z WC <br /> OWNER ADOR LC CITY/STATEr7AP CC4 5W <br /> CONTRACTOR I PHON <br /> in <br /> CONTTILic'ORADDREM &M - CDY/STATFJZIPaa <br /> �C <br /> RF4 a1W <br /> C-57 WELL DNG LICEN % <br /> SENUMBER E% RATIONDATE <br /> PERFORATION CONTRACTOR PHONE <br /> PERFORATION CONTRACTOR ADDRESS CmfSTATI'J%JP <br /> ❑ C-57 Well Drilling Licause Number Expiration Data <br /> ❑ Bureau ofAlcohoL Tobacco and Firearty-Users of High Explosives License Number Expiration Ate <br /> ❑ CHP Nutritious Material Transportation for Explosives license Number Expiration Ate <br /> ❑ San Joaquin County Shen R-Comncr Explosives Application and Pemlil Licrnse Number Expiration Ate <br /> ❑ California Occupational Safety Health-Blaster License Number Expiration Ate <br /> REASON FOR DFffiRUCr10N ❑ Dry ❑ Replacement Well O Caved In ❑ Pt Well Inactive ❑ Test Hale <br /> Detected/Suspected Well Water Contaminantl(a) <br /> Adjvttntprepertywithrontaminadon(Address) <br /> 'Known Soil l Water contaminants at ad warm Property 1 <br /> EXIMNG WELL N Ru 1n DUAIV ❑ Open Bottom If Gravel Pack ❑ Uncased ❑ Ocher tl]P(pJl` <br /> Well Lag copy attached Cl Yes �Yo Grout Seal ❑ No ❑ Yea_ft below ground surface(1,M) HoleDhmeter inches <br /> Well Conductor Casing ❑ Yes No Depth of Conducter Casing ftbgs Dlameteraf Conductor Cming inches <br /> Well Casing Diameter _inches Total Depth JZ R Depth to Water A Depth of Casing ftbgs <br /> DESTRUCTION SPECIFICATION <br /> Sealing Material from A[/v-1(__ft bp to Spm ftbp Filler Material from ft bgs o, ft bgs <br /> Well casing to be perforated by a..r the win.inu methods: from ftbgs to ftbgs <br /> Cl Mills Knife NumbecofcuUevery Rand/or <br /> ❑ Explosives ❑ Detanetiageord ❑ withpmjectileaevery, ft ❑ withoutpmjectilc <br /> ❑ Detonating card and boosters Cl withpmjectilnevery ft ❑ withampmjectile <br /> ❑ Other <br /> Sealinp,Aaterlal ❑ Nc.t Cement(94/6bag/5-AgaIwaIrr) ❑ Sand Cement suci mtr/7gy{waler ❑ Bentonite Pellets <br /> Bentonite(20% ds) ❑ Manufacturer Spee%solids_% Name iVL 1fF Spcason File ❑ Specs Submitted <br /> Placement Method;)'Amperes ❑ F.Fall ❑ Other <br /> Seal Carol bra Complete with Mushroom Cap R bgs Cl Completem E.I tlog Suff ce Ped <br /> I HEREBY CERTIFY THAT 1 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. 1 ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT 1 AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> M M24 UR ADVANCE NOTICE REQUIRED FOINSPECTIONS <br /> COPTIUC RS SICNATUaE TRLE DATE O <br /> CD <br /> c3E�= <br /> NOV 0 2006 <br /> (� L SAN JOAGiRFI GO A TTY <br /> EN\ArCNMEI4T <br /> HEALTH DEPARTMENT <br /> - -- -' - - -- EP- �R-TMENT USE ON Y ��sT�myy �,! <br /> Applicau nAccepkd Data O 20, Area WD4'� r I <br /> Drslmcti Imp tion Ate ` Employee IDX <br /> COMMENTS <br /> PE SC Racelved Cheeldl/ Amount Dale PervsiU IovolaX WallIDX <br /> Codas Info B Remitted S.". uestX <br /> 3 L. <br /> SDD <br />