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� v <br /> NELL DESTRUCTION PERMIT <br /> Punic WATERSY5TFA1❑Yes <br /> SAN JOAQU1N COUNw ENt7NOr MENTAL HEALTH DEPARTMENT 304 E WEBER AVC 3-PL-SIvcKTOTI CA 95267 -(209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL(2091953-1697 FOR INSPECTIONS )✓XPIR£$1 YEAR FROM DATE ISSUED <br /> JONADa d Crrymr �M?anteca 95336 <br /> SS <br /> CRSTREP__ French Camp Road AP -O PARCEL Si2 'I�.ANP USE APMICATIONN <br /> OWNER Wilbur Ellis Co. PHONE 982-5400 <br /> Ow'NgRADORESB 13771 South Prescott Road CTfY15TATFlLIP Manteca, CA _95336 <br /> CONTRAcrott Clar't Well_ , Inc. T PHONE 209-462-7676 <br /> CONTRAcroRADBREss__ Charter Wax__cmrsrATFmpStockton, CA 95205 <br /> ❑ C57WELLDRtLL[NG LICUMNumsta 371560 <br /> _EXPIRATION DATE 04106 <br /> PERFORATION CONTRACTOR PHONE <br /> r PERPORATfON CONTRACTOR ADDR6a3 CITYIgTATEMir <br /> ❑ C-57 Well Drilling License Number Expiration Date <br /> ❑ Bureau of Aknhol,Tobacco and Firearms-Users of High Explosives License Number Expiration Date <br /> ❑ CHP Hazardous Materiel Transportation for Explosives License Number Expiration Date <br /> 13 San Joaquin County Sheri(f-Coroner Explosives Application and Permit License Number <br /> Expiration Date <br /> O Califomia Occupational Safety Health-Blaster License Number Expiration Date <br /> REAsoN Fog 1) TRUCTION E3 Dry ❑ Replacement Well ❑ Caved In ❑ Pit Well Inactive (❑ Ted Hole <br /> Detected 1 Suspected Well Water Contaminant(s) <br /> Adjacent property with contamination(Address) <br /> Known Sell 1 Water contaminants at adjacent property <br /> &xrmNG WELL CONST uenoN DETAILS g[ Open Bottom ❑ Gravel Pack O Unwed ❑ Other <br /> Well Log copy attached ❑ Yea O No Grout Seal b No ❑ Yes R below grouted surface(bgs) Hole Diameter inches <br /> Well Conductor Caring ❑ Yea ❑ No Depth of Conductor Casing ft bgs Diameter of Conductor Casing inches <br /> Well Casing Diameter 12 inches Total Depth_8 7-_it Depth to Water 38 ft Depth of Casing_fl bgs <br /> Ba <br /> VE=N0j()N SPga cPl ATION <br /> Sealing Material from 0 ft bgs to 87 ft bgs Filkr Material from ft bgs to R bgs <br /> Well eating to be Utfflink by one of jhe following methods. from R bgs to R bgs <br /> Milk Knife 4 Number of cuts every 1 Rand l or <br /> Explosives ❑ Detonwingcord ❑ with projectiles every ft ❑ without projectile <br /> ❑ Detonating cord andbocasem ❑ with projectiles every A ❑ witboutpznjectile <br /> ❑ Other <br /> Sealing Material ❑ Neat Cement(941b bag/5.6 gat water) Of Sand Cement 10-1 .rack mtr 17 gal water 17 Bentoolte Pellets <br /> ❑ lkatenite(20Th solids) ❑ Manufacturer Spee Y solids % Name O Specs on File O Specs Submitted <br /> Placement Method❑ Pumped ❑ Fra Fall ❑ Otho <br /> Sal Completion :K Complete with Mushroom Cap 5 ft bgs ❑ Complete to Existing Surface Pad <br /> 1 HEREBY CERTIFY THAT i HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> JOAQUIN COUNTY ORD <br /> INA STATE;;INCE <br /> RULES AND REGULATIONS 1 ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT AND ACTIVWil <br /> E CALINE LICENSE BOARD AND THAT 1 AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSA <br /> 2 EQIJ[RED FOR INSPECTIONS <br /> CONTRA CTORS SIGNATDRE T— Sec-Tres DATE13 Jan 06 <br /> 1 J _I <br /> t ; T <br /> F <br /> r � <br /> f <br /> 1 ��IA� L�'2006 <br /> O <br /> r.. - L ^ ..r_ SMIJCAQI?IN (J <br /> , <br /> r _ f rt � yjRONM�NTAL <br /> PAHTMENT <br /> DEP RTMENT..USE ON Y <br /> Application Accepted By Date _ Area <br /> Destruction Inrpectloo BY Date 17 Employee IDN <br /> COMMENTS <br /> I <br /> PE Sc Received Annual Date PerNdU InvokeN Wd11DN <br /> Codes Info B Cash Remitted Service RequestN <br /> sED.w�oat <br /> Wotl Denrvetlen rwnar <br /> tmnoos <br />