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WELL DEEWCTION PERMIT ADDEN:UM <br /> SAN R AQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE 3n°FLOOR-STOCKTON CA 95202 - (209)468-3420 <br /> NON REFUNDAABLE PE y� �-CALL 20y9� 953-761977 FOR INSPECTIONS EXPIRES I YEAR FROM DATE ISSUED <br /> JOB AAIDDDRESS 7 �'` �T ��! `M T /T CITY/ZIPty 5+101a4mboi <br /> CON"{RACTOR C�rR- ) ` ,r C t� PHONE <br /> CONTRACTOR ADDRESS -/ ] V- N r7y.�fes- 7T CIT'/S 74 <br /> WELL WATER WITH 1 1� CONTAMINANTS. <br /> ADJACENT PROPERTY AT WITH SOHJWATER CONTAINING <br /> CONTAMINANTS OF <br /> WELL LOG COPY ATTACHED JJ_Yes ❑ No DIAMETER OF CONDUCTOR CASING Inches <br /> WELL WITH CONDUCTOR CASING ❑ Yes 11A No DEPTH OF CONDUCTOR CASING ft bgs <br /> LICENSE A%_ �` TD� <br /> C-57 Well Drilling License Number o tD Expiration Date <br /> ❑ Bureau of Alcohol,Tobacco and Firearms-Users of High Explosives License Number Expiration Date <br /> ❑ CHP Hazardous Material Transportation for Explosives License Number Expiration Date <br /> ❑ San Joaquin County Sheriff-Coroner Explosives Application and Permit License Number Expiration Date <br /> ❑ California Occupational Safety Health-Blaster License Number Expiration Date <br /> WELL DESTRUCTION ❑Open Bottom ❑Gravel Pack ❑Uncased &Other <br /> Well Diameter Z k in Total Depth2-5 ft Depth to Water_,2 ft ❑Casing to be Perforated om ft <br /> Sealing Material ❑Neat Cement(94 lb bag/5-10 gal wafer) N$and Cement sack mix/7 gal water ❑Bentonite Pellets /�,�,�,�_3 <br /> ❑Bentonite(20%solids) ❑Manufacturer Spec%solids % Name ❑Specs on File ❑Spdcs Stltimitted <br /> Placement Method ❑Pumped ❑Free Fall ❑Other <br /> ❑Complete with Mushroom Cap ft below grade Complete to Existing Surface Pad <br /> METHOD OF WELL CASING PERFORATION <br /> Well casing to be perforated From It bgs to ft bgs <br /> ❑ Mills Knife Number of cuts every It and/or <br /> ❑ Explosives ❑ Detonating cord only with or without projectiles every ft (� <br /> ❑ Detonating cord and boosters with or wit opt rojectiles every ft , / /A 'U <br /> [3Other Nd1' L <br /> dEaY r/'n.1/� �/✓c. 0� <br /> t1K Other dr ->I h!� CIC- o <br /> I HEREBY CERTIFY THAT I HAVE THE AUTHORITY TOC Y DESCRIBED ABOVE FOR THIS CONTRACTOR,THAT I HAVE <br /> PREPARED THIS APPLICATION AND THAT THE WORK WH.BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE <br /> LAWS, RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS CURRENT AND ACTIVE WITH THE CALIFORNIA <br /> CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION LAWS. <br /> INIMUM 24 HOUR ADVANCE NOTICE <br /> (REQUIRED FOR INSPECTIONS (/ <br /> SIGNED / TITLE Yt-✓rl (JV F•/�),;LCt DATE 3 2- <br /> DEPP�A TMENT USE ONLY <br /> Application Accepted By ` Date ' <br /> Destruction Inspection By Date Employee ID# 5 <br /> COMMENTS G r , <br /> lG J <br /> u e <br /> PE SC Received Check#/ Amount Date Permit/ Invoice# Well ID# <br /> Codes Info B Cash RemittedService Request# <br /> 10 2�S <br /> EHD43-02-008 /p yr a c6on Peemit Addc ' w <br /> 3/3/2004 <br />