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JOB ADDRESS 61 U 1 'i, ti ',A.A 50*, 12—(1\ crry/Zip TVC,1 , CA 9 5-3 7 7 <br />CROSS STREET .c I.--V-‘,-, V\--'( APN '9C)ei t t 01 ° <br />4 e <br />PARCEL SIZE /5 'LAND USE APPLICATION # <br />OWNER '..)) )6`' "'A..... ," 3•I>'N PHONE 5 10 --7 3'1 ();)-7--C7 <br />OWNER ADDRESS ') Lo i), 0 i \-\."-Y...5-4'1/4, RA CITY/STATE/ZIP l',..— ci C 4- `1";-1 77 <br />/1 1 <br /> PHONE ,-*-2.---S. 5 15 11 fri.-- 7 Ls. CONTRACTOR(-06 4'1 41), j ..."" St ,cv-IP"A Yvvy i."1—`-' I. <br />J , <br />CONTRACTOR ADDRESS ' ''' t:)( (.4 (‘-' t CITY/STATE/ZIP ICI,..1,1V-e--2,-, (--- C-7 -1 5 <br />, 7, <br />t.3 <br />Nyir C-57 WELL DRILLING LICENSE NUMBER •Ci )'C 5 "II EXPIRATION DATE j . / L7/1 2 6 ri <br />PERFORATION CONTRACTOR PHONE <br />PERFORATION CONTRACTOR ADDRESS CITY/STATE/ZIP <br />0 C-57 Well Drilling License Number Expiration Dale <br />0 Bureau of Alcohol, Tobacco and Firearms - Users of High Explosives License Number Expiration Date <br />0 CHP Hazardous Material Transportation for Explosives License Number Expiration Date <br />0 San Joaquin County Sheriff-Coroner Explosives Application and Permit License Number Expiration Date <br />0 California Occupational Safety Health - Blaster License Number Expiration Date <br />REASON FOR DESTRUCTION 0 Dry 0 Replacement Well p3 Caved In 0 Pit Well 0 Inactive 0 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 0 Open Bottom 0 Gravel Pack 0 Uncased 0 Other <br />Well Log copy attached 0 Yes 0 No Grout Seal 0 No lit Yes ft below ground surface (bgs) Hole Diameter inches <br />Well Conductor Casing 0 Yes 0 No Depth of Conductor Casing ft bgs Diameter of Conductor Casing inches <br />Well Casing Diameter 6.7 inches Total Depth ft Depth to Water ft Depth of Casing ft bgs <br />DESTRUCTION SPECIFICATION / / (,,,, <br />Sealing Material from ''.34 ft bgs to ''''' Ft bgs Filler Material from ft bgs to ft bgs <br />Well casing lo be perforated by one of the followina methods: from ft bgs to ft bgs <br />0 Mills Knife Number of cuts every ft and/or <br />El Explosives 0 Detonating cord 0 with projectiles every _ ft 0 without projectile <br /> <br />0 Detonating cord and boosters 0 with projectiles every ft 0 without projectile <br />0 Other <br />Sealing Material Neat Cement (94 lb bag/5-6 gal water)X Sand Cement /0,3 sack mix/7 gal water Bentonite Pellets <br />Bentonite (20% solids) Manufacturer Spec % solids 11, Name Specs on File Specs Submitted <br />Placement Method Pumpeo Free Fall - Other <br />Seal Completion Complete with Mushroom Cap ft bgs Complete to Existing Surface Pad <br />I HEREBY CERTIFY THAT I 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 I AM IN COMPLIANCE WITH ALL <br />WORKERS COMPENSATION LAWS. <br />/MINIMDM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br />CONTRACTORS SIGNATURE ( TITLE DATE <br />Application Accepted By <br />Destruction Inspection By <br />COMMENTS "Veil Kir/Ay/VI Co) <br />57 'Let I (i (4,4.n C.,,j ,t/fAj <br /> Date <br />-71e ctc,-; <br />Employee ID# <br />I) <br />PAYMEN <br />RECEIVE <br />J.A0UAGQ3littli rV — ENvIR • „' • <br />Lit DEPARTmEN1 <br />Area <br />DEPARTMENT USE <br />Date <br />WELL DESTRUCTION PERMIT <br /> <br />Oh tZ <br />PUBUC WATER SYSTEM CI Yes No <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 East Hazelton Avenue - Srockroki CA 95205 - (209)468-3420 <br />NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />PE <br />Codes <br />SC <br />Info <br />Received <br />By <br />'*----lChecki? <br />Cash <br />Amount <br />Remitted Date Permit./ <br />Service Request It Invoice ft Well IDS <br />,13d (To Lb, <br />4 <br /> IN-fic, lila) elsplu, s12-tt ijit .2)9 <br />EHO 43-08 <br /> WELL DESTRUCTION PERMIT <br />A Plf1/10