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&ELL DESTRUCTION PERMIT <br /> • PUBLICIAATERSYSIEM❑YIN Pklo <br /> SAN JOAOUIN COUNry ENVIRONMENTAL HEALTH DEPARTMENT 301E WEBER AVE 3-a-STOCNTON CA 9511TJ -(109)466-3410 <br /> NON-REFUNDABLE PERMIT N' CA 09 953-7697 FOR INSPECTIONS EXPI S 1 YEAR FROM DATE ISSUED <br /> JOBADDl1FSS r7 m CITTIZIl, <br /> AIL-J-�-/o"/ PARC6LSIEe'< LAND WEAPPIUCATONY _� Dp <br /> CROSS STREET , / PN <br /> OWNER _ p PHONE; <br /> D� a/ X CITYISTATFILP —C• <br /> OµT![RADORLSIjJ 11J—/1�1 .6 <br /> CONTRACTOR C t _ I� J-Lj2T�-C�- -� PNONB r <br /> CANTRACTORADORESS I�y.fl CMISTAWDI, <br /> W alS7 WELL DRILLING LICENSE NumBEREWIRATION DATE <br /> PERFORATION CONTRACTOx PHME <br /> PERMRATIONCONTRACTORADDRESS CITY/STATTILIP <br /> NOV ?f <br /> ❑ C-57 Well Drilling license NumberExpiation Datc <br /> ❑ Bu=uofA]cohOI,TOba.0 ..d Firatms-us erHighF plosive License Number Expiration Dale <br /> Ll CHP Hanrdaus Material Tansporblim for Explosives Li«nsc Number Expimlion Date <br /> ❑ San Joaquin County Sheri R-Coroner Explosives Application and Permit Li«ibe Number Expiarion Datc <br /> ❑ Cahimmia Occupational Safety Health-Bbstan Li«nsa Number Expiation Date <br /> REASON POR De6rRUrnON ❑ Dry ❑ Replacement Well ❑ Caved In ❑ Pit Wellmotive C3Tat Ho,e <br /> Deuxued I Stop«ted Well Water CORlaminant(s) <br /> Adjacent property with aoalaminalbn(Address) <br /> Known Soil I Warr enataminula m adjacam property <br /> •• NG WELL CON0KOIUCTI NVETAiu ❑ Open Bottom ❑ Gavel Pack ❑ Unused U Other w <br /> Well Log COpymbIted ❑ Y« ❑fro Gwm Sea! ❑ No ❑ Yes_R below gmndwrtece(ngs) Hole Dknxler inchm LN <br /> Wall Conductor Casing ❑ Ya No DeptM1 of Conal�t��ar{{C��asing Diameter or Conductor Cusingin<h. (/u <br /> Well Casing Diameter inches Tot.]Depth._/ 611 Deem to Nlkr ft Depth of Gtlng Rhga Z <br /> Orcror CTION$ ICATION 11—�`' <br /> Sealing Mourtal from Rbpw fthgs PillerM.]edd from ftbgam ftbp <br /> well casing to berirforaled by oro of the followine metlmds: from ftb6s to Itbgs Q <br /> ❑ III,Knlfe Numbes of cub every _R and 1 ar <br /> xpladvea W Demnafingcod 0 with pmjccIil..Wy It without projectile <br /> ❑ Deton<dngcodandbaastea ❑ a,hh PmJ«tilaerrry_ ft ❑ widloutpmjectila <br /> ❑ Other <br /> Sanding Malt-IRI ❑ Nest Cement(94 JhhaI?J-dgofansrJSsnd Cement .radmh 17 gal water 13Bevlodk Pelktl <br /> ❑ Benlonik(lox mlWa) ❑ Menufaclura Spec Y.aolida_Cl% Name ❑ $pecaon File O SpNTSubmined <br /> Placement Method❑ Pumped ❑ Fr«Fall ❑ Other _ U <br /> Seal COmpRtkn ❑ Compker with Mxehroom Cap _R by ❑ Complete to Exkdsg Surface Pad <br /> I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> JOAQUIN COUNTY ORDINANCES, STATE LAWS AND RULES AND REGULATIONS I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT 1 AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> Iryl�1 b VAN E NOTICE REQUIRE F dSPECTIONS <br /> GOMMCTORB$IONATURE PI/IV/ TITLE- DATE <br /> Llk9t:�' <br /> c-l" I pqd <br /> RECENT <br /> IVED �" ' " P' �3d � ?O !U <br /> Mar z a 2oo� l !d .3L�CJ- <br /> °ri1� <br /> HEALTHDEpAH 20 � <br /> i ell <br /> DEPARTMENT USE ONL <br /> Appliurion A«eptd By _ Dam S 2V CS Area <br /> Dpwclion In,p«ticn BY Desk / Employee IDR bfYf L tAGD.z+� <br /> COMMENTS 9j J CO l�4 tAe G-.J S''7:E <br /> PE SC RN,,d od CAeakN Amount Permlu Invoke We111DR <br /> Codes Ido B Remlued Dale BerNa Re uatR <br /> a1373 llCl Q I �t-.L'O o QCp r-12y <br /> wall Dmrunen Nana <br /> Elmant, <br /> intranet, <br />