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_ WELL DESTRUCTION PERMIT ADD NDUM REEVED <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE 3n"FLOOR-STOCKTON CA 952 (2j09)��4ii68--33n4200c <br /> NON-REFUNDABLE PERMIT C;AI,L(2()9)x)53-7697 I'OIt I NSI'ECTIONNS EXPIRES 1 YEAR FROM <br /> �er <br /> JOBAnnxEss PomENVIRONMENT bo Ranch Facility at 24100 S. Lammers Road CITY/ZIP Tracy 95376 NTHEA'�� <br /> V&W Drilling / M.J. Kloberdanz & Associates <br /> CONTRACTOR PHONE 916-777-4100 / 209-577-6186 <br /> CONTRACTOR ADDRESS P.O. Box 576961, Modesto, CA (MJK&.A) CITYISTATE/ZIP Modesto, CA 95357 y <br /> WELL WATER WITH Gasoline CONTAMINANTS. <br /> ADJACENT PROPERTY AT WITH SOIL/WATER CONTAINING <br /> CONTAMINANTS OF <br /> WELL LOG COPY ATTACHED ❑ Yes MXNo on file at SJDEH DIA mETER OF CONDUCTOR CASING inches <br /> WELL WITH CONDUCTOR CASING ❑ Yes OK No DEI TH OF CONDUCTOR CASING ft bgs <br /> i <br /> LICENSE ! <br /> MM C-57 Well Drilling LienseNumber C-57-720904 Expiration Date 4-30-07 <br /> ❑ Bureau of Alcohol,Tobacco and Firearms-Users of High Explosives Li ease Number Expiration Date <br /> ❑ CHP Hazardous Material Transportation for Explosives Li ense 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 XYiOther Monitoring Wells <br /> I <br /> Well Diameter 2 in Total Depth 20 & 4 Oft Depth to Water -12' <br /> ft 13 Casing to be Perforated from ft to ft <br /> Sealing Material IN-Neat Cement(941b bag 15-10 gal water) ClSand Cement sack mix 17 gal water ❑Bentonite Pellets <br /> ❑Bentonite(20%solids) ❑Manufacturer Spec%solids % Name ❑Specs on File ❑Specs Submitted <br /> Placement Method ®)Pumped ❑Free Fall ❑Other <br /> ❑Complete with Mushroom Cap 3 ft below grade 17 Complete to Existing Surface Pad <br /> METHOD OF WELL CASING PERFORATION NA <br /> Well casing to be perforated from -ft bgs to ft bgs i# <br /> ❑ Mills Knife Number of cuts every ft and/or L <br /> is iiMM COPY <br /> ❑ Explosives 17 Detonating cord only with or without projectiles every ft C <br /> ❑ Detonating cord and boosters with or without projectiles every ft <br /> � r <br /> ❑ Other <br /> 11Other <br /> i C <br /> I HEREBY CERTIFY THAT 1 HAVE THE AUTHORITY TO COMMIT THE ACTIVITY DESCRIBED ABOVE FOR THIS CONTRACTOR,THAT I HAVE <br /> PREPARED THIS APPLICATION AND THAT THE WORK WIL BE DONE IN ACCO ANCE 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 /> M:INIMUh9 24 II.017R ADVANCE NOTICE.ISE UIItC+.D FOR INSPECTIONS <br /> SIGNED TITLE DATE <br /> DEPARTMENT USE ONLY � <br /> Application Accepted Bylr Date �-N O Area Z <br /> Destruction inspection By L(�-yyt �.� Date ! Employee 1139 62f <br /> COMMENTS 5 4s2 aJ t' <br /> 1 <br /> PE Sc Received Check#/ Amount Date Permit/ Invoice 4 Well ID# <br /> Codes Info By Cash Remitted Service Request# <br /> 150 <br /> `4 ; TIf <br /> EUD 43-02-008 Well Destruction Permit Addendum dm <br /> 3/3/2004 <br />