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P -YELL DESTRUCTION PERMIT <br /> - - YUBL]i11'ATER Sti'S'I'F.M❑Ycs.�No p;�j� � `���8 <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 600 EAST MAIN STREET-STOCKTONCA 45202-(209)"&,3420l-J (� <br /> NON-REFUNDABLE PERMIT CAI.x, .209 95.-7697 FOR INSPECTIONS FXPIRFS I YEAR FROM DATE I QN7�LENTT111"'1��EALT <br /> JOBADDRPSS 31YZetF T ctTvfLiP " �� VI T�SERVICE-S <br /> .:OWNER O PHONE D <br /> �I OWNER ADDRESS CITYISTA'fEILD' <br /> CONTRACTOR Melee Ir� PHONE � ¢� <br /> CONTRACTORADDRESS Y f. CITY/STATE2e <br /> [3C-57WELLDRILLING LICENSE NUMBER G ` EXP IRA .DATE <br /> PERFORATION CONTRACTOR 'DN PHONE ` v . <br /> ii PERFORATION CONTRACT ORAI DRESS fit/ a —CITY/STATE • (� « <br /> �C-57 Well Drilling License Number 1 .� Expiration Date LV <br /> �3 13Bureau of Alcohol,Tobacco and Firearms-Users of High ExpSosives License Number Expiration Pate <br /> i <br /> ❑ CHP Hazardous Material Transportation for Explosives License Number Fxpiration Date <br /> .❑ San Joaquin County Sheriff-Coroner Explosives Application and Permit License Number Expiration Date <br /> ' ❑ California Occupational Safety Health-Blaster License Number Expiration Dale <br /> REASON FORDESTRUCTION ❑ Dry ❑ Replacement Well ❑ Caved In ❑ Pit WellInactive ❑ Test Hole <br /> Detected Suspected Well Water Contaminant(s): <br /> Adjacent property With contamination(Address)' <br /> Known Soil/Water contaminants at adjacent property: <br /> EXISTING WELL CONSTRUCTION DETAILS ❑ Open Bottom 17 Gravel Peck Cl Uncased ❑ Other <br /> Well Log copy attached VYes- ❑ No Grout Seal ❑ No y GrYes ft below ground surface(bgs) Hole Diameter ncbes <br /> q Well Conductor Casing Q /ss ❑ No Depth of Conductor Casing—ft bgs DiamdtrplConductor Casinginches <br /> Well Casing Diameter inches Total Depth��R Depth to Water fl Depth Of Casing -.- ft bgs <br /> DESTRUCTION SPECIFICATION ` '' 0 t I/ <br /> Sealing Material from �ft bgs to OOS ft bgs Filler Material Q fA from r� ft bgs to lhh7 Rbgs <br /> I` Well casing lobe perforated by one of the followine methods from R bgs to R bgs <br /> ,❑ Mills Knife Number of cuts every ft and 1 os - <br /> k ❑ Explosives 17 Detonating cord: ❑ with projectiles every R ❑ without projectile <br /> ❑ Detonating card and boosters: ❑ with projectiles every R ❑ without projectile <br /> C3 Other <br /> Sealing Material if Neat Cement(94 1b bag/5-6ga1 water) ❑ Sand Cement sack mix 17 gal water ❑ Bentonite Pellets <br /> 0 Bentonite(20%solids) ❑ Manufacturer Spec%solids % Name' O Specs on File C3 Specs Submitted <br /> ;i Placement Method V Pumped ❑ Free Fall q - O Other <br /> Sea3l Completion: V( Complete with Mushroom Cap ft bgs Complete to Existing Surface Pnd <br /> :11 HEREBY CERTIFY THAT I 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 I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. - <br /> MIhP_19LIM 2414010%AD �CQE/�NOTICE REQLiIRED FOR INSPECTIONS .. <br /> CONTRACTORS SIGNATURE: ��" TrfL - <br /> rr. <br /> JF <br /> T­t _ _ <br /> i - <br /> , <br /> i <br /> DEPARTMENT USE ON <br /> Appliuden Accepted B -Date Q Area <br /> Destruction Inspection B Date Fmplvyce IDM Q� <br /> COMMENTS <br /> P <br /> PE $C Received Checkal Amount Permit/ <br /> Codes I.F. H Cash -R•mitled Date Service Request N IuvoiceMWeII IDM <br /> 773 <br /> EI1Das-02-MwER - W.11 D?arO kn Fdmia AdderA—dac <br /> 9/l[1200T - <br /> ,k <br />