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08.'19/2019 08:41 Canepa S Sons (FAX) P.002/004 WELL DESTRUCTION PERMIT PUBLJC WATER SYSTEM El Yes ❑No SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPT 1898 East Matelton Avenue-STOCKTON CA 952056232-(209)468-5420 NON•REFUNDAB PE MIT CALL(209)253-7697 FOR INSPECTIONS FX RES 1 YkIR F DATE ISSUED n JOB ADDRESS -^' CITvIZIP a CROSS TREE-r PN PARCEL EtN11 BE APPLICA ION llOWNER PHONE OWNER A RESB CITYISTATC/7JP CONTRACTOR C.kNEPA AND SONS,INC. PHONE (2 091 532-1 1 3 6 CONTRACTOR ADDRESS 14384 CULSTA COURT CITY/STATE/ZIP SONOI C? 95370 C•57 WELL DRILLING LICENSE NUMBER 425749 ERPIRA DATE 07,131/2020 I PER70RATIONCONTRALTO PHONE^/ ,�'} ��'c,p ) ~ PERFORATION CONTRACTOR ADDRESS 4 {rte _ CITY/STATBIYIP Vey +�r� ❑ C-57 Well Drilling License Number !J�I plrstlon Date Bureau of Alcohol.Tobacco and Firearms-Usera of High Explosives License Number pirotion Date CHP Hazardous Material Transportation for Explosives Licence Number 6tplretlon Dale 12 San Josquin County She6ff-Coroner Explosives Application and PelmIi License Number Expiration Date Califomla Occupational Safety Health-Blaster License Number Expiration Date REA8ON FOR DESTRUCTION ❑ Dry ❑ Replacement Well CI Cavcd In ❑ Pit Well Inactive ❑ Test Hole Detected I Smpocted Well Wator Contaminsnt(s) Adjacent property with contamination(Address) Known Soil/Water contaminants at adjacent property EMADI G WELL CONSTRUCTION Dmii j tat Opor Bottom ❑ Gravel Park ❑ L'ncased ❑ Other Well Log copy attached n Yes No Grout Seal ❑ No ❑ Yea ttbelow grouno surface(togs) Hale Dlameter I O Inches Well Conductor Caelnt Yes ❑ No Depth or Conductor Casing h 8Diameter o1 Conductor Casing inches Well Ca%ing Diameter)D inches Total Depth 7 ft Depth to Water tl� h Depth of Caeing tt bgs D1iaTRDCTIOV SPECIAICATION /�A�M Sealing Material from It bH h PA to bga Filler Material from ft bgs to bge Well casing to be perforated by one of the following mnlhnd y' ❑ Mills Knife Number of cute every h and/or C �'�• Explosives❑ Detonating cord ❑ with projectiles every rL ❑ Without projectile �D kL9t^❑ Detonating cord and boosters ❑ with projectiles every ft ❑ without projectile ❑ AIG (/vG ?Sealing Material Nest Cement(94 lb bag/5-E gal water) Sand Cement sack mix/7 gel water Bentonite PegetaO, Bontonito(20%solids) -Manufacturer Spec%solidsY% Name Spees on File Specs Submitted � AQV/pN Placement Method umped Froc Fal Omer /R0 N Lou Soal Completion Complete ushroom Cap f1 bps Complele to Existing Surface Pad rh pFFIvTA�7-)' I HERESY CERTIFY THAT t HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN ARTMFIyr JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION LAWS. I IU 48 H ADVANCE NOTICE RECIUIR_. R INSP CTIONS CONTRACTORS SIGNATURE TITLE DATE�� 1 I _.I. 1 I _i i_ l i-I I ! I ' _.• j I... I !,. I _l�.��I I l ..I- __.! I_. I J J I I i f I l i I I � ',�. I I I I I ! t.... i I � I I- I ( i j I. ! . I I I_I_.I.__IA _ �• �G�(i'J I I ' I . l .I. 1. - - I...! - I —..Iyl ., I,. ' L.....I_ I I- -I_ L—I SNI_ "I� . 1.. j I ,., J ._ . I. . 1. I ;. ( I ..I �.. I. J. ..., Aji HENT USE O L�� Application Accepted By Date Area, Destruction Inspcetlon By ., Dete 3 Employee IDN COMMENTS PE 8C Received Check#/ Amount Permit/ Codes Info a cash emitted Date Service Re uestlt Invoice# W¢II ID# fnu2m.14 J T (1 2019 1 (1 A��_p p C 0 0 R e C 2 i v?U l m e o,A U';, 1 7. L Q� 7 ; 3 7 A M IVO. J 3 U U e7c—/ q 9 WELL DE6TRUCTION PERMIT rQV.Ised 4114116 ! l