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co W' L DESTRUCTION PERMIT <br /> PUBLIC WATER SYSTEM [:]Yes ❑No <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE 3"o FL-STOCKTON CA 95202 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL(209)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> /� 9 r - r <br /> JOB ADDRESS�r( 740400 Nee 4� n CITY/ZIP ._ , <br /> CROSS STREET j��'.cf` /�f7 APNZ�S Z` 2 PARCEL SIZE` ND USE APPLICATION# C <br /> OWNER ` ' mil t PHONE <br /> I �.' <br /> OWNER ADDRESSf,Qy�C 700 PIi/.-1 <br /> ,IS�a�� /i CITY/STATE/ZIP Rr � <br /> CONTRACTOR ( pp p y PHONE -::F Z04 ` <br /> CONTRACTOR ADDRESS tl 11 -IL {K✓✓'�f �`` CITY/STATE/ZIP oAAk ��4af <br /> C-57 WELL DRILLING LICENSE NUMBER/O ,Pe,zz- EXPIRATION DATE <br /> PERFORATION CONTRACTOR PHONE <br /> PERFORATION CONTRACTOR ADDRESS CITY/STATE/ZIP <br /> ❑ C-57 Well Drilling License Number Expiration Date <br /> ❑ Bureau of Alcohol,Tobacco and Firearms-Users of High Explosives License Number Expiration Date <br /> ❑ CHP Hazardous Material Transportation for Explosives License Number Expiration Date <br /> ❑ San Joaquin County Sheriff-Coroner Explosives Application and Permit License Number Expiration Date <br /> ❑ California Occupational Safety Health-Blaster License Number Expiration Date <br /> REASON FOR DESTRUCTION ❑ Dry ❑ Replacement Well ❑ Caved In ❑ Pit Well OW11nactive ❑ Test Hole <br /> Detected/Suspected Well Water Contaminant(s) <br /> Adjacent property with contamination (Address) <br /> Known Soil/Water contaminants at adjacent property <br /> EXISTING WELL CONSTRUCTION DETAILS Open Bottom ❑ Gravel Pack ❑ Uncased ❑ Other <br /> Well Log copy attached ❑ Yes e_ o Grout Seal ❑ No Yes�_ft below ground surface(bgs) Hole Diameter inches <br /> Well Conductor Casin ❑ Yes o Depth of Conductor Cas ng tt bgs Diameter of Conductor Casing inches <br /> Well Casing Diamet inches Total De h t Depth to Water ft Depth of C Thg ft bgs <br /> DESTRUCTION SPEC ICAT � <br /> Sealing Material from ft bgs to /V ft bgs Filler Material 671 Z.V f om �/ bgs togsWell casing to be Derforat one of the fo owin ethods: from ft bgs to <br /> ❑ Mills Knife Number o cuts every ft and/or <br /> ❑ Explosives ❑ Detonating cord ❑ with projectiles everyft ❑ without projectile <br /> ❑ Detonating cord and boosters ❑ with projectiles every ft ❑ hout projectile <br /> ❑ Other <br /> Sealing Material ❑ Neat Cement(94 Ib hag/5-6 gal water) ❑ Sand Cement ' suck m gal water ❑ Bentonite Pellets <br /> ❑ Bentonite(20%solids) ❑ Manufacturer Spec%solids % Name ❑ Specs on File ❑ Specs Submitted <br /> Placement Method ❑ Pumped ❑ Free Fall ❑ Other <br /> Seal Completion ❑ Complete with Mushroom Cap ft bgs ❑ Complete to Existing Surface Pad <br /> I HEREBY CERTIFY THAT 1 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. 1 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 /> MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br /> CONTRACTORS SIGNATURE Z/11 CL f?di Az. TITLE t 1Q✓, DATE <br /> �� fl FEB8 2008 <br /> SAN JOAQUIN COUNTY <br /> 41 ENVIRONMENTAL <br /> c r HEALTH DEPARTMENT <br /> N <br /> DEPA/R T11 <br /> ENT USE ONI`Y <br /> Application Accepted By Date G,s4 � Area <br /> Destruction Inspection By Date Employee ID# <br /> COM TS L 1 r t ! <br /> PE SC Received Check#/ Amount Date Permit/ Invoice# WellID# <br /> Codes Info Bash Remitted Service Request# <br /> �V a J 6,00 ' ?>3-3 <br /> EHD 43-02-008 Well Destruction Permit <br /> 1/27/2005 <br />