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Z- a f.YS <br /> owneRADn �`�, i agss P.O. BOX 1 1 CITY/STATE/ZIP STOCKTON , CA 9570 i `. <br /> ' CONTRACTOR_HENNINGS RROS _ Hill I ► NG ACO , 1,Nr. PHONE 545-1125 <br /> CONTRACTOR ADDRESS 3525 PELANDALE AVE. CITY/STATE/ZIP O <br /> MODEST , CA953516 <br /> 4 C-57 WELL DRILIANG LICENSE NUMBER 990A13 EXPIRATION DATE MAY 31 , '2006 <br /> PF.RPORATION CONTRACTOR same as above PHONE <br /> PERFORATION CONTRACTOR ADDRESS PITY/STATE/ZIP— <br /> )b C-37 Well Dniling License NumberE�tz�p�m�otion Date <br /> XI Bureau of Alcohol,Tobacco and Firearms-Users of High Explosives License Numbed tx*)Tration Dale <br /> ❑ CHP Hazardous Material Transportation for Explosives n/a License Number Expiration Date <br /> ' XJ San Joaquin County Sheriff-Coroner Explosives Application and Permit License Number — Expiration Dale A—6—0 5 <br /> XI California Occupational Safety Health-Blaster License Number$9 18789 1 4 Expiration Date 5–6–09 <br /> REASON FOR DESTRUCTION ❑ Dry ❑ Replacement Well ❑ Caved In ❑ Pit Well Mi Inactive ❑ Test Hole <br /> ' Detected/Suspected Well Water Contaminant(s): <br /> Adjacent property with contamination (Address): <br /> Known Soil/Water contaminants at adjacent property:' ay EXISTING WELL CONSTRUCTION DETAILS ElOpen Bottom jp Gravel Pack ❑ Uncased ❑ Other <br /> Well Log copy attached ❑ Yes I No Grout Seal ❑ No ❑ Yes ft below ground surface(bgs) Hole Diameter inches <br /> Well Conductor Casing ❑ Yes ❑ No Depth of Conductor Casing ft bgs Diameter of Conductor Casing inches <br /> ' Well Casing Diameter_�_A inches Total Depth 190 ft Depth to Water_ A Depth of Casing A bgs •� <br /> r+ <br /> DESTRUCTION SPECIFICATION <br /> Scaling Material from 0 ft bgs to 160 B bgs Filler Material from R bgs to it bgs p <br /> ' <br /> Well casing to be Perforated by one of the followina methods from Q it bgs to C3 f bgs t0 be d21S21m1f12d Cl <br /> IX Mlllsxnife Number ofcuts every it and/or e5' after well is t.v.'d t <br /> ❑ Explosives ❑ Detonating cord: ❑ with projectiles every It ❑ withoutprojectile 1/7 <br /> ' ❑ Detonating cord and boosters: ❑ with projectiles everyft ❑ without projectile <br /> ❑ Other <br /> Sealing Material 13 Nest Cement(941h hag 15.6 gal water) p,l Said Cement 3 0_,...3 sack mix f 7 gal water ❑ Bentonite Pellets <br /> ❑ Bentonite(20%solids) ❑ Manufacturer Spec%solids % Name ❑ Specs on File ❑ Specs Submitted a. <br /> Placement Method X7 Pumped 13Free Fall ❑ Oti:ci A <br /> ' Seal Completion: ❑ Complete with Mushroom Cap _ft bgs fx 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, 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. 'Q <br /> MINIMUM 24 HOUR ADVANCE NOTICE REQUIREp FOR INSPECTIONS <br /> ' CONTRACTORS SIGNATURE: }J. >> <br /> `; TLE: SUPERVISOR IATE: A-30-04 <br /> ` <br /> PestSon <br /> 1 <br /> r I <br /> N t I I 7N/ <br /> ?fE'M <br /> SU <br /> !`JEC T <br /> I <br /> 9 2004 F � ► {� <br /> i <br /> SAN JOAONIMGAL yr I <br /> HFA HDEPApTMENT <br /> I <br /> DEPARTMENT S ONLY p' �1 Application Accepted Py A-sG�ti D to r Area G�! <br /> Destruction inspection By D to Employee ID# <br /> COMMENTS_ ` -t.. S wt( .,, /'t. _� •5 . - i ir. '^ <br />