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WELL DESTRUCTION PERMIT — <br /> PUBLIC WATER SYSTEes <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE T°PL-SI'OCKTONC 19124109)46&3420 <br /> NON-REFUNDABLE PERMIT CA 09 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> p% <br /> JOB ADDRESS CITY/ZIP ^^�� PI <br /> CROSS STREET APN � PARCEL SIEcJ3 P JLAND USE APP i(CATION# e <br /> OWNER /RI 1� n PHONE r 'moi <br /> OWNERADDRES4Pf 1 Lt X - CITY/STATEIZIP <br /> CONTRACTOR l.( <br /> - �IK= UX—LC_ A� PHONE_A / <br /> � <br /> COWRACORADDRESSQ- ) G V E:: UQ N 14 CITY/STATLP <br /> WT37 <br /> WELL DRILLING <br /> '11 L[CENSE NUMBER IO <br /> EXPIRATN DATE <br /> x'A/ <br /> PERFORATION CONTRACTOR PHONE <br /> PERFORATION CONTRACTOR ADDRESS D CRY/STATVZIP <br /> ❑ C-57 Well Drilling License Number Expiration Date <br /> ❑ Burrau ofAlcobol,Tobacco and Firearms-Users of High Explosives License Number Expim6on Date <br /> ❑ CHP Hamrdoes Material Transportation for Explosives License Number Expiration Data ' <br /> ❑ San Joaquin County Sheriff-Coroner Explosives Application and Permit License Number Expinlion Date <br /> ❑ California Occupational Safety Health-Blaster License Number Expiration Date <br /> REASON FOR DEBTBOMON ❑ Dry Cl Replacement Well ❑ Caved In ❑ Pit Well nsative ❑ Test Hole <br /> Detected/Suspected Well Water Contaminants) <br /> Adjacent property with contamination(Address) <br /> Known Soil/Water contaminants at adjacent property ( ' <br /> EXISTING WELL CONSTRUCTIONDETAILS ❑ Open Bottom ❑ Grovel Peck ❑ Uncased ❑ Other (:v <br /> Well Log copy aoached ❑ Yes ❑ o Grout Seal ❑ No ❑ Yes Rfl�below ground surface(bp) Hole Diameter inches <br /> Well Conductor Casing ❑ Yes No Depth of Co If coon Casing /v Diameter of Conductor Cuing inches <br /> Well Casing Diameter inches Total Depth ft Depth to Water It Depth of Caring flbgs �Z <br /> DESfRUCr1ON SPECIFICATION <br /> Sealing Material from ftbgsto ftbgs Filler Material from ftbgsto ftbgs <br /> Well casing to berfeQ orated byoneofthefollowlnemethods: from ftbgsto RbgS (p� <br /> ❑ pulls Knife Number ofeuts every Rand/or <br /> •`•d,'/Explosives BYDetonating card VI with projectiles everyfl �aithoutprojeclile COSI <br /> ❑ Detonating cord and boosters 13with projectiles every fl ❑ without projectile <br /> ❑ Other <br /> Sealing Material ❑ Neat Cemaut(94/bbag/5-6ga/waren) Sued Cement sack Bra/7 gal water ❑ Bentonite Pelleta <br /> ❑ BentoniIrG0%muds) ❑ Manufacturer Spec hsolids % Name ❑ Specaon File ❑ SpecSSubutmed <br /> Placement Method❑ Pumped ❑ Free Fall ❑ Other <br /> Seal Completion ❑ Complete with Mushroom Cap ftbgs ❑ Completeto Existing Surface Pad <br /> 1 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 1 ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> /Rxj!�fAAE NOTICE REQUIRE F SPECTIONSDATE 3 <br /> CONTRACTORS SIGNATURE TITLE <br /> �{4�. <br /> r-� r {-f i j i- r i <br /> L! eh)LJ <br /> /{/�1y(/// <br /> F1ECU <br /> t r <br /> A M5 1 <br /> � ld <br /> SAN JOAGJIN <br /> 6001,1v <br /> �IML <br /> A (vik F!A)I c rf <br /> ENVtHOFPENT l� <br /> HEALTH / 2� 1 rl,� O <br /> L I,J 1�� q 1 <br /> r DEPARTMENT USE ONL <br /> Application Accepted By G ,C Date .$- 2rF OS Arca <br /> Destruction Inspection By Date V EmployeeID# OFfF1-46' Y0 <br /> COMMENTS &w GON-r-ArAcr <br /> PE SC Received Check#/ Amount Data Permit/ Invoice# Well ID# <br /> Codes Info B Remitted Service Request# <br /> 4373 (fo/ 9 ( Lf .So•DO o Qpp e{2µ <br /> EHD4M2"a` wdlIX mown Tamm <br /> Jn7RN5 <br />