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WELL DESTRUCTION PERMIT PUBLIC WATERSYSTEM O Yes O No SNI JOApU W COUNTY EWMtONMEMAL HEALTN DEPARTMENT BOB E MAIN STREET-STOCNTON CA9S202-(209)4993420 NON-REFUNDABLE PERMIT 'CALL 209 953.7697 FOR INSPECTIONS EXPIRES EXPIRES T YEAR FROM DATE ISSUED .Ion ADDRESS � C"IZIP aP�C Z L Cl7oae STREET - APN Z' PA toll SOP�LWDU EAPPIIGIFONM C OWNERNIee��S /✓/K{AIL�Y� (( //JJ I PHONE&0 --/ OJUNER ADnRBss -wtA- r l A.�.cl-1 Tc.� CRY/STAIE/LP C j. D cosimCtooI AAA aA �,r UN11II - PHONE CONTF(AC ORADDn .11 l A16- N CINISTATF21P C)d-C-57 WELL DRILLING LlwmsiE NUMBER &Z7 EXPIRATION DATE a ,043( PERPoRA CONm lrwt 'C a !' PHONE'r. PERFOl 110N CONTRACTOR ADDRESS -C"/STATE/Zip ❑ C57 Well Drilling .I . .. LJcame Number - Expiration Date ❑ . Bureau of Alcohol„Tobscm and Firearms-UMM DI High Explosives License Number Expiration Date -❑ CHP Hazardous Material TYanspOr2tiDn for Explosives . I Ucense Number Expiration Date ❑ San Joaquin County Sheriff-Coroner Explosives Application and Permit License Number Expiration Date ❑ California Occupational Safety Health-Blaster I License Number Expiration Date REANNFORDESTRUDTON 121' Dry r3m Replaceent Well ❑ Caved In Pit Well ❑ Inactive ❑ Test Hole Detecte"uspected Wall WaM Comaminam(s) I Adjawnt propertyvith contamination(Address) Known So4lWaler contaminants at adjacent properly EXdmNGWE"CONETxucT1oHDll ($Open Boron Cl Gravel Pack ❑ Uncalled ❑ Other Well Lop copy attached ❑ Yes' T�Na Gran Seal ❑ No "❑ Vea_RDelow gmuntl sudaee(tgs) HOM DIamNr Inche Well Conductor Casing 13 Yes U.aJI-� Depth of Conductor Cuing ftbgs Diameter of Conductor Casing IrwMnches Well Casing MairMall Inches Total Depot R7ft Deptho Water ft Depthof Casing10 it bgs DESTINKmON SPECIFICATION - Sealing Material from R Dgs tc -' ft bgs Filler Materialfrom R bgs to R bog Well casing to be DBAOn!t d by we of the fdllowmD methods: from R togs to ft logs ❑ Egiis Knife Number of cuts every fl and/or ❑ Explosives❑ Detonating mrd ❑ with projectiIw every ft ❑ Wthcut pmjeNle . { ❑ Detonating oDrd and boosters ❑ with projectiles awry .. . ft ❑ without projectile .. 1 ❑ Dow Seeing Material ❑ Neat CemerN(9416 ba9/55 gal wato0❑ Sand Cemard sour mLY/7 gal water ❑-Bentonite Patient ❑ Bwdcnlle(2O%solids) ❑ Manufacturer Spec%solids_% Name ❑ Spew m File ❑ Specs Submitted I PIacament Mathed `❑ Pumped " Cl Free Fall ❑ Other r - ^"-1 1 "-1 , Seth ComplaUon U Complete with Mushroom WP fl bgs ❑ Complete to Existing Surface Pad I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES„STATE LAWS, AND RULES AND REGULATIONS. 1 ALSO CERTIFY THAT MY REQUIRED LICENSE Lia CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION LAWS. .. MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED F05INSPECTIONS CcNrauum”SIaNATuu� L Pi Tm.B, )u(I'ON DAre 6-a®=ii -�- -I NY PAYIAE T"+ - _ - RSC-ENED" i N12 .0 {011' NIV1aeMMFaIA 1 f j .I.. BaAl1 t 0EPMib DE ARTMENT USE ON Y Application Accepted By 'Date Area Destruction Inspection By sr%� Dose 6 Employee IDM COMMENTS�' - PE SL Raralwtl Amount Pem IV Codes Info B Cash Renitted Data Sanice Reguenta Invoice IF we IDR 1 t X