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WELL DESTRUCTION PERMIT 4, <br /> PUMIC WATER SYSFEM❑Yes/`hl <br /> SAN JoAQulN COUNfY ENVIRONMENTAL HEALTH DEPARTMENT 794 E Wmn Avg J"FLOOR-STOCncrom CA 45202 -(204)4683420 <br /> NON-REPI)NDABLE PERMIT CALL 2119 9.53-7697 F INSPECTIONS EXPIRES I YEAR FROM DATE IV.cl I ED <br /> JORADDRES6 ZQQZ0AJ- 40WQ`g— C^ CrryMP weapdak <br /> OIANCR 4APiet IanDNE o <br /> OwN clig ADDRESS �p.r CfT41STATVLIP (/ <br /> CONTRACTORII•41 ,- PHONICONTRACTOR I n2 <br /> CoNTRAt'roRADDREss 'J CITY/BfATFa,Z4, ,Q <br /> C-57 WFA t.DRILLING LICENSE NUMBER r 1 EXPIRATION DATE C-07 <br /> PERYORATiON CONTRACTOR Peaty <br /> PSRFORAnON CONTRACTOR ADDRESS CTITMrArtair <br /> O C-S7 Well Drilling Liceue Numb" Fxpiranon Dane <br /> ❑ Bureau of Alcohol,7obecco and Firearms-Users of High Explosives License Number Expirenan Dau <br /> ❑ CHP Hazardous Materiel Tnnaportation for Explosives License Number Expiration Date O <br /> ❑ San Joaquin County ShenffCoroner Explosives Application and Permit License Number Expiration Date <br /> ❑ Califemia Occupational Safciy Health-Blaster Liceme Number Expiration Date <br /> REASON FOR DLYTRU'Crlex ❑ Dry ❑ Replacernent Well ❑ Caved In ❑ Rt Well j<lnactive ❑ Test Hole <br /> Detested i Suspected Well Water Con4 ml.anl(sj- <br /> Adjacent property w,th contattllDadoa(Address)- <br /> Known Soil l Water contaminants ai adjsocnt property: <br /> ERUNING WELL CONSfRt:CTwo-q DTTAttz Open Hotton ❑ Gravel Pack ❑ Uncased O Other <br /> Well Log copy attached ❑ Yes No Gruut Seal ❑ No 11 YM R below ground surface(hgs) HoleDiameter inches <br /> Well Conductor Casing ❑ Yes,No Depth of Conductor Casing A bgs Wander of Conductor Casing inches <br /> Well Caring Diameter inches Total Depth R Depth to Water�_R Depth of Casing R bgs r <br /> DEsTRug:TION SPECIFICATION 1� <br /> Seallug Material from_/_ft bgs to I_fl bgs Piller Material fmm R bgs to R bgs <br /> Well casing to be perforated by one of the.[Dllywlr,eanetlt_+ds from R bgs In R bgs <br /> ❑ Mllb Knife Number of cute a uy R and/or <br /> ❑ Cxp)utives ❑ lktonating cord. ❑ with projectdez tvwy - ____R ❑ without projectik <br /> ❑ Detonating card and boosters: ❑ with pmjectiks every R ❑ without projectile <br /> ❑ (Aher <br /> Sealing Material 13 Nod CoauM(94Ib Edg/3-6 gal water) ❑ Sand Cement jack mix!7 go]water 'W-Benloolne F01W. <br /> ❑ Beolusyte(20%solids) O M1mufieuarc %solids % Natpt ❑ Specs on Fik ❑ 5pccs Submitted <br /> m <br /> Placeent Method ❑ Pumped ' Free Fall ❑ Olhgr <br /> Seal ConTletloa: .< Complete with Mushroom Cap A hgy ❑ Complete tb EslsHag Surface Pad <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE HONE IN ACCORDANCE WITH SAN <br /> JOAQUIN COUNTV ORDINANCES,STATE LAWS,AND RULES AND RSCULATIOMS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND TRAT 1 AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> MINIIMMUYMJ�`J2"OJU/yR_ ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br /> CONTRACMRS S117NATURE: /`�`^"� v`1t�7-� T1TLE:�Wt'••;� DATL:/I—L3- <br /> - — I tit <br /> . —1-.. -- <br /> - ��- - — -} <br /> --1 _ <br /> t 1 <br /> NSR <br /> I <br /> DEP RTMENT USE ONLY <br /> Application Accepted By Date Aro' ►.� / . <br /> Destruction Inspection By _ - f)8te ��� C7� Employee 1DII �/ AjOtl / <br /> COMMENTSA CA got <br /> '"(J L <br /> PE SC Received Ch*CW Axa" Doh PerMILI [­it.M Well IDS <br /> Codes Info B Remktad Service Request N <br /> 3S a b S 53 <br /> END 41-02-001 W,II r>� r Paws A4sm,naa teal k 04-01 <br /> vrw <br />