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WELL.DESTRUCTION PERMIT <br /> PUBLIC WATER SYSTEM ❑Yeg�4 <br /> 600 E MAIN STREET-STOCKTON CA 95202-(209)466-3420 <br /> SAN JOAOl11N CouNTY ENVIRONMENTAL HEALTH DEPARTMENT" _ EXPIRES')YEAR FROM DATE ISSUED <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS S Z�-/D <br /> fo:.tlE/Y �- •-a.. (Ld. CiTYIZtP Laa1 + 9 <br /> JOs ADDRESS r Q <br /> CROSS STREET-1:3 <br /> cw e ti APN Q 070-23 PARCEL SIZEIgS LAND USE APPLICATION "L� <br /> PHONE^J Ll'7 d��Z <br /> OWNER o SZ.4�?7 y <br /> _CITYISTATElZIP l� 1 <br /> OWNER ADDRESS I� 2 L •�� - PHONE 31 <br /> CONTRACTOR •` ' r <br /> CtTYfSTATrJZIP 1 <br /> CONTRACTOR ADDRESS <br /> ? CS7 WELL DRILLINRG LICENSE NUMBEa5 1 L 3 EXPIRATION GATE <br /> 'PHONE <br /> PERFORATION CONTRACTOR CITYISTATHZtP <br /> PERFORATION CONTRACTOR ADDRESS F <br /> License Number �� Expiration Date <br /> ❑ CS7 Well Drilling Expiration Date <br /> ❑ Bureau of Alcohol,Tobacco and Firearms-Users of High Explosives .License Number,_� Expiration Date <br /> t_icense Number - j <br /> ❑ CHP Hazardous Material Transportation for Explosives Expiration Date <br /> ❑ San Joaquin County Sheriff-Coroner Explosives Appllcation and Permit License Number Expiation Date <br /> ❑ Califomia Occupational Safety Health-Blaster Inactive ❑ Test Hole L <br /> REASON FOR DESTRUCTI� &Dry ❑ Replacement Well ❑ Caved in Pit Well ❑ N j <br /> Detected suspected Well Water Contaminant(s) <br /> Adjacent property with contamination(Address) <br /> Known SdUWater contaminants at adjacent property----- <br /> ! <br /> roperty__ -- <br /> ❑ Gravel Pack ❑ Uncased ❑ Other 9p <br /> E_xmSITNG WE�GONSTRUCmON DETAILS ❑ Open Sodom inches <br /> Well Log copy atmchad ❑ Yes ❑ No Grout Seal ❑ No ❑ Yes—ft groundDi�tesurface rof Conductos) Hole rs Casing inches l� <br /> Well Conductor Casing❑ Yes ❑ No Depth of Conductor Casing - ft Depth of Casing ft bgs �q <br /> Weil Casing Dlarrleter <br /> Vnches Total Depth_ ft Depth to Water_ <br /> imRKMSPECIFICATION 4ew 5 � ` from O ft bgs to�_ft bgs <br /> ial from- 7 ff bgs to�-ft bgs Filler Material-�+^�� —ho rfor by one Of the foilowlna methods: frOm ft bgs io ft bgsnife Number of cuts every hand/or- ft ❑ wthout projectilelves t7 Detonating cord ❑ w th p oject les every ft ❑ without projectile <br /> ❑ Detonating cord and boosters ❑ with projeciilas every -- Bentonite Pellets <br /> of wata ❑ Sand Cament sack mrx?gal water <br /> Sealing Material � Neat Cement(941b ba9/5-6 g � p Specs on File L' Specs Submitted <br /> Bentonite(20%solids) -] Manufacturer Spec%Solids_% Name <br /> } Placement Method 17 Pumped G Free Fall D Other <br /> Seat Completion D Complete with Mushroom Cap It bgs o 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 /> { CURRENT ANDNACTIVE WITH THESTATE LAWS, AND RULES AND CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I GULATIONS. I ALSO CERTIFY THAT <br /> N COMPLIANCEWLICETH ALLNSE IS <br /> I� <br /> WORKERS COMPENSATION LAWS. <br /> MINIMUM�4 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS U <br /> DATE zov <br /> I` CONTRACTORS SIGNATURE Ali TITLE__ <br /> [ j t_ 1 I I 1 I I I i -���,fu �. � -.�-j--�---•t -�,-i„- <br /> t <br /> I I1. CIA, _ <br /> MA'R_'I -2 <br /> I iSAN�- ul�p {- <br /> �'HEAC7N DE MENTAL <br /> EPAR � ONLYI I 1 <br /> �'°'-.. _-`='"' "^'-"a'--"•' T M E N T USE <br /> 2g1 <br /> Application Accepted Date y �& D Area <br /> Destruction Inspection Date I Employee ID#_ <br /> COMMENTS - <br /> — <br /> PE SC Received Ch Amount Date Permit/ Invoice# Well ID# <br /> Codes Info B Cash Remitted Service uest# <br /> �( 3 � S3 B" �sd•o•,7 16 0 2C1a5 t�-7�7 <br /> { WELL DESTRUCTION PERMR <br /> EHD 43-06 <br /> 01&07 <br />