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a�&seaeese®B.R+ <br /> (,. WELL DESTRUCTION PERMIT P(BI2CwnTERsysrFN3vs❑ a <br /> liow <br /> 3"E WEBER AVE 3a"FR.-STOCKTON CA 95202-(209)468-3420 <br /> SAN JOAQUIN COUNTY ENVIRGHMENTAL HEALTH DEPARTMENTy <br /> CALL(209)953-7697 FOR IN PECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> NON-REFUNDABLE PERMIT <br /> CITYIZIP �- Z <br /> .los wpoacss <br /> tia <br /> APN_ E1�2� PARCEL SI]l - LwrvO USE APPLICATION M <br /> CROS4 STREET ~� ((�/ <br /> d !� PHONE —�,) <br /> OWNER CIMS <br /> OWNER ADDHEM t �UTY _PHONE r�� <br /> CONTRACTOR v f F O S C,. / _ CrfY/S ��' ( ? r',_ Q •2 <br /> CONTRACTOR ADDRESS <br /> :>,o 11 r/ Y - 3o — O <br /> [3C-ST WELL DRILLING LICENEENUMBE0. <br /> �i`)_7 EXPIRATION DArE <br /> PNOrvE <br /> PERFORATMN CONTRACTOR CT'/STATPIZIP <br /> PERFORATION CONTMC oda ADDRPSS ERn0r1 Date <br /> License Number xpl <br /> ❑ C-57Bureau <br /> Well Dulling Ex i Otion pm <br /> Licenu Number p <br /> ❑ Ban9n Or Alcohol,Tobal Tran FiramLfrExplof High Explosive License Number Exptmhon Dam <br /> ❑ CHPoauin Co ary She Tf-Corm rEx for Explosives License Number Expiration Date <br /> ❑ Sen Joaquin Cowry Sheriff-Coroner Explosives Apphcation and Permit Liccnu Number Expiration Dem <br /> ❑ California Oaupetionai Safety H"Ith-Blaster <br /> REASDN MR DMRECEION ❑ Dry ❑ RWlaccmet Well ❑ Caved In ❑ <br /> pit Well Inactive ❑ Tat Hole <br /> Det«red/Sospated Well Water Contaminaat(s) <br /> Adjacent property with ernisminatlon (Address) <br /> Known Soil/Water'net amimnts a adjacent PmPMY <br /> EavirrING WE,i C t'f D s I ❑ Open Boh. ❑ Gravel Pack ❑ Uncased ❑ Other <br /> Well Log copy attached ❑ Ym ❑ No Grant Seal ❑ No 1�6-Yes-_�fl below ground surface(bgs) Nok Dlemeter _inches <br /> Reil CorMudor C"ing ❑ Ya ❑ No Depth of Conductor Casing ft bgs <br /> Diameter of Conduemr Cadn inches <br /> Well Casing Disorder_rlv�_incha Total Depth_ft Depth to Water It Depth of Casing ITbgs <br /> DF-STR <br /> f,,. <br /> NSPECIFl <br /> Sealing Material Tom ftbgsm flbgs Filler Material tram ftbgsm Rbgs <br /> Well easing to be�erforaled by f h rlbwi met8odr rrom it SE, to Tip r) <br /> ❑ Mills Knifr Numbcr of cuts every flandlor <br /> ❑ Ezplusives ❑ Daonatingcom [3withprojectilaevery ft (3withnotprojectili, - <br /> ❑ Detonating cord and bixonc. ❑ with P.jCCilaevery ft ❑ wideautprojetph, <br /> ❑ Other fTx <br /> Sade,Mnerial ❑ Neat Cement(PI/h hag/5-6 Kol water) Sand CementIT3 .sad m4/7 gal water ❑ BFRtan t.Pelkts 1 11 <br /> ❑ Bentonite(20%iolid%d ❑ Manufacmrm Spec%ulids_% Name ❑ Spason Fik ❑ Spas Submitted <br /> Placement <br /> Method�Pumped ❑ Free Fall O Olher <br /> Seal CooPledian Complem with Mmbmom Cap ft Inge, ❑ Campkte to EziatlRg Surrue 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 ORDINANCES, STATE LAWS,AND RULES AND REGULATIONS. i ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> IMUM 24 H UR ADVANCE NOTICE REQUIRED FOR INSPECTIONS �(TT ,�T a^� <br /> CONnucroRS SlcnwrURE l\� Tm.E Y� Ch,�w.— DATE t1t19-,264S7 <br /> O-12 WO- <br /> 12 <br /> Cj,._k, <br /> PAYMENT <br /> RECEIVED <br /> SEP 2 0 2005 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> D PA TMENT USE ONL <br /> Application Accepted BY Date 'Z2,V 6 Ara 2 5 C4/ <br /> spadon BY Dam �/ 2TC= EmploYa lDM <br /> Destruction lnY 9 <br /> COMMENTS pla - r t i4 0 ✓iC�C( CG'QS �1 <br /> aU�Sf dr c_.: - c j aS -c•trucct- dr.w a. 2+., a as s,.�?-.Ya.. <br /> LLSz Cz.'rs�w, f1 �ws- 30' <br /> PE SC I Raeived Cha1N/ Amount Date PertNt/ Invokat WRIIIDB <br /> Cad" IDfa B Cash Remitted ServfnR ueHLi <br /> G 15 zo o5 e "7 <br /> Esm un:-aa wrn Domaim Poor <br /> tmaaos <br />