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f}If ! y7 <br /> WELL DESTRUCTION PERMIT <br /> PUb _rVATERSYS7EM❑Yes No <br /> i <br /> I <br /> (\ <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WE DER AVE 3"FL-STOCETON CA 95202-(209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL(209)953-7697 FOR INSPECTIONS E PIKE 1 YEAR FROM DATE ISSUED { <br /> rn <br /> Jos ADDRESS CITVIZiP <br /> CROSS STREET APN (O"-r-2-4 --3 a PARCEL Size=_'IAND USE APPLICAT N G <br /> OwNEp PHONE <br /> Eat ADDRESS CITYISTATFIZIP LLLeee <br /> • CONTRACTOR - PHONE 'SS <br /> CONTI ACroitADDRESS _ ClTY1STATFIZIP L <br /> I C_S7 WELL DRILLING LICENSE NUMBER 3CJ&_2 E7LPIRATION DATE <br /> PERFORATION CONTRACTOR PHONE ' <br /> 1 PEpPORATION CONTRACTOR ADDRESS CrrWSTATElZIP <br /> rV el-'C-57-57 Well Drilling Licerrse Number 3t9q e,%J Expiration Date 7—_4/-1p <br /> ❑ Bureau of Alcohol,Tobacco and Firearms-Users of High Explosives License Number Expiration Date <br /> ❑ CHP HazardousMaterial Transportation for Explosives License Number Expiration Date <br /> ❑ San Joaquin County SherifPCoruncr Explosives Application and Permit License Number Expiration Date <br /> ❑ CaIifamia Occupational Safety Health-Blaster License Number xpiration Date <br /> r <br /> TRtlCTION ❑ Dry ❑ Rcplacemcnr Wcll ❑ Caved In ❑ Pit Well laactivc ❑ Tdt Hole <br /> ected Well Water Coutsminant(serly with contamination(Address)Water contaminants at adjacent property <br /> ExispNG WELL CONmtuCrioN DEfh t_- Open Botwm ❑ Gravel Pack ❑ Uncased El Other <br /> )s / <br /> Well Log copy stitched ❑ Yes No Grout Seal ;/Na ❑ Yes ft below ground surface(bgs) Hole Diameter inches <br /> Well Conductor Casing ❑ ^Yes 13 No Depth of Condutter Casing ft bgs Diameter of Conductor Casing inches <br /> Well Casing Diameter�d v inches Total Deplh ft Depth to Water fl Depth of Casing ft bgs <br /> DESTRUCTION SPECIFICATION •+ <br /> Sealing Material from 16C) R bgs to 3 ftbgs Filler Material from ft bgs to R bgs rn <br /> Well casing to be oerforatggi by one of the foliowina methods: from ft bgs to Rbgs <br /> W❑ ills Knife Numberofcuisevery Rand Ior ' <br /> sploslves ❑ Detonatingcord ❑ with projectiles everyft ❑ without projectile <br /> ❑ Detonating cord and boosters ❑ with projectiles everyit ❑ without projectile <br /> ❑ Other . <br /> Sealing Material ❑ Neal Cement(941b hag 15-6 gat water} WISI.aCement /d2,3 rack mix 17 gal water ❑ Bentonite Pellets <br /> 13 Bentonite C209'6 wilds) 17 Manufacturer Spot%solids % Name ❑ Specs on File ❑ Specs Submitted 3 <br /> Placement Method❑ Pumped ❑ Free Fall Cl Other i <br /> Seal Completion z <br /> Complete with Mushroom Cap _ fl bgs ❑ Complete to Existing Surface Pad <br /> 1 HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE M ACCORDANCE WITH SAN <br /> JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS. 1 ALSO CERTIFY THAT MY REQUIRED LICENSE 1S <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT 1 AM IN COMPLLANCE W1TH ALL <br /> WORKERS COMPENSATION LAWS. <br /> MINI UM 24 HOUR VANCE NOTICE REQUIRED FO INSPECTIONS <br /> CONTRACTORS SIGNATURE ' T1TLE DATE/O~PI Dd <br /> JI- <br /> 1 I1 _ <br /> - } -r I ,. _.L t_�_� T ..�... _ _L_� PAYMENT-r. <br /> F <br /> i <br /> _ <br /> _ _t t t-r_ <br /> 4 4.�: -T--T C- 2. 2008.: <br /> L sSAENA—LJOt.AQUIN <br /> COUNTY. <br /> - $ tNVIEA ' <br /> I+ T— T' <br /> 4- <br /> DEPARTMENT USE ONLY <br /> Application Accepted B Date l 'Z a Area <br /> Destruction inspection Dam /c3tf' ...._.. Employee IDN 53 Ota 1 <br /> COMMENTS <br /> Thr aEk-rZ:L_ -I , rat �i� .-cy. _ _0 a7�d ��1►r <br /> r <br /> PE SC Received Check#/ Amount Permit! 1 <br /> Cods Date Imolce# we111D# <br /> Info B Remitted ac Se"IceR uest# <br /> 4.3-7 1 tps S 4 -L$ <br /> EN043.02-0tx Wen netl i_Pnmu <br /> lmrmos <br />