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WELL DESTRUCTION PERMIT PUBUCWATERSYSTEM ❑Yes ❑No SAN JOAQUIN COUNTY E.IRONMENYAL HEAIYN DEPARTMENT 600 E MAW STREET-STOCKTON CA 95202-(20g 468J42O NON-REFUNDABLE PERMIT CALL 209)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDflE68 OO I$ ora- tCS S ^of"�j` C"Yalp S•1-DL)SINNA jm VY,1 N C✓ _APN NA PARCEL SIZE CROS95 STREET _ LAND USE APPLICATION It OMTIEP �\T �C.T.S. 1^IO/CCL,` M r 1 IC PNONE LO'L -�'1- 1$� Q i� OWNER ADORE �4�SnJ C-Il�Ia OST• _Qn/STATERIv �i'UfIL"NN CPr /�Zbz CO N T R A rA'M-Ao i PHat RL6 WYS� w7W £.?.1y CONTRACTOR ADDRESSf„"ITO 61"A Ql4W'2 rJJ21- 12-s CITYISTATFIZIP Fall Lh 5�5i3o t/J - C-57WELLDRLLING LICENSE NUMBER ExPIRATIONDAT`- ' PERFORATION CONTRACTOR PHONE ¢3f6. EaaY• f/L9 e PERFORATION CONTRACTOR ADDRESS %('3X /7 CG L.?KIG cTYSTATaCnP PLinc rdoJ . CA (4 C-57 Well Drilling License Number L93T.433 Expiration Date >•TI••�t1 '.. Bureau of Alcohol,Tobacco and Firearms-Users of High Explosives License Number Expiration Dale CHP HaFBMous Material Transportation for Explosives License Number Expiration Date San Joaquin County Sheriff-Coroner Explosives ApPlice6Dn and Permit ❑cense Number Expiration Dale California Occupational Safely Health-Blaskr License Number Expiration Dale REASON FOR DESTRUCTION ❑ Dry O Replacement Well 0 Caved In IT PN Well „�Inactive O Teal Hde DMacdif/Suspected Well Water Contlminant(s) ppp Adjacent property With contamination(Address) 6 Known Soil I Water contemlnaofs at adjacent property._..___.-- -----------------_------ f, WELL CONSTRUCT ON QfiTAILS ❑ Open Bolrom 0 Gravel Pack ❑ Unused ❑ Other_.,__ __. Well Log Copy ahached X Yes ❑ No Grout Seal ❑ No la Ye8)1e3 hUdCWground.mNe(bgQ Hole Dunamr_ T .0. Well Contludtor Casing❑ Yes �kNo OepM of eontludor Casing It togs Diameter of Conductor Gsing InGlas Wolff Caslsg Diameter Z .inches Total Depth lTA__If Depth to Wider- ItT_. it Depth of Casing_ .._.XDgs DA IT, LT ONS,TI.FCATmN h Sealing Material from —_Q..-._R togs toL1D._._It Cgs FIIIexMaerial_.__-L}gu}—.--____.,_.from.,--l� it togs lo_11p Xbgs Well easing W beep Hosted by one of the following m¢thods:�J V l� �� n. from__ 0 it bgs to,�_it hips II ❑ Mills Knife __Number of Cuts every_ M1 aM/or 0 Exploaivoe 0 Detonating Card 0 with projediles every._..............R O wBhoul projeclil. ❑ Detonating Card and hoosters 0 With projectiles every.......,....._N 0 without p.ja,fle ❑ Sealing Material Neat Cement(94 N bag 15-6 ga/water) Sand Cement _sack mix 17 gal wafer Bentonite Pellets I; Bentonite(20%solids) Manufacturer Spec%solids % Name Spee on File Specs Submitted ii'' Placement Method Pumpetl Free Fall Other Seal Completion Compete with Mushroom Cap-..-., togs Compkte to Exiati gSurlace Pad 1 HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN - JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION LAWS. i MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS CONIMcrORSSIGNATURE `'-.111 G�5-- TITLE Mgr DATE 10/6/09 L C, P $f /✓1/Noll (1[.Mry-4A Vt1n0['t6.1 ~mu.� wa,( �pccv�coP T� s�ePr1, MOVED IILf 0 9 8009 ENViR NMENTNEALTh PER I T/SERVICES �-�- �-�. DEPARTMENT USE ONLY Appliulion Accepted BY—�` -..--�--- Date....(_ Desimclion Inapectbn BY._—�...lN%aaN/\/�`�` -- DateEmployee IDA _..... _ COMMENTS PE SC Received ChecNN/ Amount Date Permit/ InvoiceN Well lDp _ Cotlee Into Cash RamlUod Service Reggost A._.—_ so b39S ro o EHO 43 WELL DESTRUCTION PERMIT 1005112