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05/29/2008 13: 37 7073745677 WOODWARD YARD PAGE 04/04 <br /> ME) <br /> t� v F DD WELL DESTRUCTION PERMIT <br /> Jy n p� PUBLIC WATER SYSTEM C]Yes C]!.k, <br /> EMWAONMc..TAL HEAI.TII DcrwRT%IFrvT 60()F.As1 1%1-1 S'rnte'r-STOCKTON CA"JIHZ (209)40"429 <br /> �)E[� <br /> NONV-REFUNDABLEPritmIT <br /> EIY^(VfS i,d Afa i �Su' ��MQ7�C1 Sf ref- ' CIT1'/Zv 0 cLt q .� <br /> -q,•r.p� �c f->,as o�.nd �� c+f i(' fRn rwr>rcgt5- 933�96sy � <br /> PER1MI /`�s64 klhl g 7"q Ben1P S cee+ CITY/STAT 7,10' Sass Efts�t ice cA 9y " <br /> CnvTRxwfi' ofAEC+, lbrMetip Ar-019 PHo'e.9,.N6- C794-93ei� <br /> t Cu.TRnCTT;laA.uu4Eka�,�S6j;�ni.ttE�P Circ�P CITv/SCATW7..lY��P#Q , CA,.9y 9 <br /> 0 C-57 WELL DRILLING LICEFati NUsaa&• Exr RAT1oY DATE �r _ <br /> Yan YVaa7'1VT CUn-fW[IV ICOIdd4XrAdYMU•v'E '^f 1 /� Q�J <br /> YtaroarrtO�Co,tTRACTVtt AV4R[SA tier,Ro -w,,,�`C1TwsTnTrl7iy [`,t11, p�"-I— g A <br /> C.37 Wcll Drilting Li -Kvrmber�,C Q; l Gxplr9nOn Dtlet<P' ,L <br /> ❑ BUrIAw of Alcohol.Tohacc.and Firearms-Urera nr High E.plosives Llwmtae Number_� ErtpirNion Dale, <br /> ❑ CHP NwArduub Muterlal Tamallo wion for Explosive[ License Number 6xpiution D.I. <br /> ❑ San Joequm County Sheriff-Crooner Expinsires Application and Permit License Nunib) f?xpiralion Wfc <br /> Cl C011Mni.t]e..pmion.l S.r y Fl.elth Bla'w Lica»o Numi- CAPlnllon Dare <br /> REA5gh PV.Dt'$ravC'TW,,, 0 Dry ❑ R placcmqu W"cll ❑ Caved In ❑ Pd M.11 Inunis'c O '1'c.l Hnk <br /> Dcicvl.d/Suspected Well Water C.Runni...If$):yId n k Aa�Jr1 _ <br /> Ad'acent properly with conmminatlw v.(Addito):, <br /> Knuen tip, !Wa qr.unto Inanh a(adJ.crn(Pmpcn r P I-� GLt <br /> Exla'r:RO WELL CONSTRUCTION DETAIL$ ❑ Oprn Bnllnm ❑ cjmvcl PA k 13Uncascd [3 Other 'j- p,fljy p _ <br /> wall I,qscampy.H.ched ❑ Yaa )11 N. Gro-(S-1 ❑ No ❑ Y.a ,fl tmlaw Sraund♦urfua(bgs) Hole Dlarnelel"__ inches <br /> W Il Conductor Caelog O Ycs 0 No Dcpthof Conducl.r Cosine=.`_Ilb)(s Di+.mdcr.(Conductor Casln�— jnchos <br /> W.II Caring 01—ter_q inch.. T.(.10cpth VnknVt4lj n Dsptht.Wal.rl/nkf.BlUft D Dtmh.f C.slugitnkrlG4Jp nhg$ <br /> DASTR IICTIOft St'CCIF ICATION <br /> Seahat h1arevial from, Lh fi bgs w Q n h1(a o ft-- /h n bp to�„n by6 <br /> Wd1...i.,t.be t,erfoeAtcd by RyI f the fell—l—u,cebtnjs (roar ft bgs Ji hyo /^v ale•ff Vv° <br /> ❑ hiills KpIR Number Df cws cvcrY ,,,R andior SQf/ <br /> ❑ Exploairc. O Dca+nutingeon): ❑ Wlth pf0j"liles every 0 ❑ wnhuut pmjeeliln <br /> Q DCMnaUng onrd d�oos)grs: ❑ Wllh ptojcc(i les every R ❑ without pmjenil. <br /> Sealing hiaterid ❑ tient Csment fP'f fh bag/S•d lfrtf hmeYJ ❑ S.od Cemeni n,rk wiT/7 gal Nater 0 Bent.nite Pelleb <br /> ❑ Benlonhe(70 W solids) ❑ M.nvrpc(umr Spm%solids SX Nan1. ❑ 5pres m[•Ile 0 4ccs Submiltnd <br /> Placement Sleth.d ❑ Pumped ❑ Face Fall Other <br /> 5a.1 C.mpl+(loot ❑ Cbn,yla.Wit),Muahmom Cap fl bgs 'K ComplelP to EsleUng S.M..Pm <br /> 1 HEREBY CERTIYY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK XVILL of DONE IN ACCORAANCB WITH SAN <br /> JOAQUIN COUNTY ORDINANCES.STATE LAWS,AND RULES AND REGULATIONS. 1 A1,50 CERTIFY TIIAT MY REQUIRED LICENSE IS <br /> CURRENT AND ACTIVE.WIT11 THE CALIPORNIA CONTRACTORS STATE LICENSE BOARD AND 1'HA'r I AnI IN CONIPIAANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> CONTRwCTORS SIGNATURE: TITLE.TM.�'tt .r DATE: <br /> App14ca0-n AcreptW-1 —_ Dao, <br /> Dcaltvdion Inap-jinn BY DateEnr 10 <br /> p ycc IDP <br /> COMMENTS �.W1 kisu7lnl IL..P <br /> PF, SC R i-d Cb.tvJ Am.un1 P.rmltf <br /> Codes I.f. (tr Cash R.millcd Date Service Pe westa I.—I-0 vY.11IDN <br /> vzL o- i oosvo <br /> s(tD.)w�oe,ven W.wD. —Mn...10 <br /> w)I,zrlrn nao�u..n.ae. <br />