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WELL DESTRUCTION PERMIT <br /> SAN JOAWIN COUNTY ENVIRONMENTAL HEALRI DEPARTMENT PUBLIC WATER SYSTEM ❑Yes 9Np <br /> - <br /> NON-REFUNDABLE PERMIT-' 800 E MAIN STREET-STOCKTON CA93202-4209)468-342, <br /> /, CALL 209 953.7697 FOR INSPECTIONS EXPIRES T YEAR FROM DATE ISSUED <br /> Joe ADDRESS -1 S'64 W I-I w I Z <br /> 7 cmmP LD4D/ CiF 4 S�y z <br /> CaosssTaEEr12.41 APM OSS- /fie So P. <br /> Dr�ly O '�Nl l rDS PARCELS- DUs.APPLILATGNI > <br /> OWNER PHONE e <br /> OWNERADDRESS CIWISTATFJZip <br /> CONTMCTOR ILa.�T'I- (�w'rs W.r:IlS t {� �,� PNDNE Z 27 <br /> ❑OrmMLTOR ADDRE36 r.a �l /6 -6 CITY/STATEMP' 9 <br /> lA <br /> f.' ray/ <br /> ❑ CST WELL DRILLING LICENSE NUMBER. Sf N Ss 1 73 EIPIRARON DATE 74// <br /> PERFORATION CDwmiuuc DR PHONE <br /> PERFORATION CONTRACTOR ADDRESS P ----- <br /> HO _ <br /> NE <br /> ❑ C¢7 Well Dnlling License Number <br /> ❑ Bureau of Alcohd,Tobacco and Firearms;-Users of Hi h Fplosives License Nmber - Epired.,Date <br /> FXPiredm Date <br /> ❑ CHPHanrdms Matenlal Transportation t.rEmloslves License Number <br /> ❑ San Joaquin County Shang- Expiration Dab <br /> p ly Safety <br /> HINT Explosives Appliratlm and Permit License Number Expiration Date <br /> ❑ California OcwpaOonai Safary HeaIN-Blaster License Number Expiration Data <br /> REUtRUCTION ❑ Dry ❑ Replacement Weil 13Cavetl In O Plt Weil ❑ Inactive 11 TOM Hole <br /> Well Water Conti minant(a) <br /> Adjacent Property With contamination(Address) <br /> Known SoMater contamirunta at adjacent property <br /> EnanNc WELL DONRTRUC O DETAILS <br /> ❑ Open Bottom ❑ Grant Pack ❑ Unnaed ❑ Oner <br /> Well Log-PY attached ❑ Yes O No Grold Swl ❑ No ❑ Yea__fl below pound surface(bps) HOW Dlarrlabr Inc,p <br /> Well Conductor Casing❑ Yes C3 Ho DePln of Conductor Casing it bill DMmebr of CendudartYelrq_Ino <br /> Well Coming Derrell., b inches Total DePN�fl enes, Cl <br /> DOMWWa r Le ft gpth al Dealing Rope <br /> DEETRUCTN]M1 FMAnI <br /> Sealing Materiel from 5� fl bps to-,3_flogs Filler Maternal Ri,S,n)ha� from Itbgsto flbgs <br /> Well casing to be Perforetsd by One of the folimina method • Dom fl bg5 to ft ops t <br /> ❑ MITIS Knife Number of arts every flamdl.r - (1 <br /> ❑ Explosives❑ Debnating mrd ❑ wittlprojecdleSeveryff ❑ v4thoutprojec3le <br /> ❑ Other D Detmating oordantl boosters ❑ wit,projectiles every It ❑ without pmjecdle ,hCC <br /> Sealing Material D Neat Cement(94/6ba9/ 69slwate00 Sand Cement sack mlk/l pal water $ Bentonite Pslk4 ' <br /> u SeMonha,(20,aolide) ❑ Manufacturer Spec%wilds % Name ❑ SpersFile ❑ Specs Stemmed <br /> Placement Method ❑ Pumped ❑ Free Fan D Other <br /> Seal CMPIOUcn ❑ Complete With Mushroom Cap S It bgs ❑ Complete to Existing Surface Pap Y <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN II <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 1 AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS, <br /> ' <br /> MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br /> CONTPACTORa SIONATURF �C✓/ ��,� Tr E 9,955 K— DATES) 7-20/e <br /> ( }_. <br /> a <br /> -IEj <br /> ,1 A - I <br /> Fl <br /> EDEP <br /> E <br /> I 1 <br /> Application Accepted By Dab $l?r10 <br /> DeInspectionlon Inspection ey Anon <br /> Z. /Z��i• Pm 199— lit r <br /> COMMENT I <br /> PERaa1Wd Checld! Amount <br /> Coosa Yrfo Raw Da, Date Service,R uest0 Invoice WSII 106 <br /> 'f.3'T3 /�/ a so•tnJ 405yqlait <br /> TWD Sales <br /> teal.) WELL DESTRUDTION PERMIT ` <br />