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r <br /> j WELL DESTRUCTION FZ16S 'ON Nd� :' 0Z0Z l '.ldy awil paA [ ;D;� <br /> �a PLIBLIC WATER SYSTEM 0 Yes Q No <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPT I B68 East Hazelton Avenue-STOCKTON CA 95205-6232-(2091468-3426 <br /> )VON-REFUNDABLE PERMIT = - = EXPIRES 1 YEAR FROM DATE ISSUED <br /> JON AODRESs E 0 Ashley Lane Cm�mP Stockton CA 9 S'?l 2 <br /> 75Yyy������ Y <br /> CRCSS STREET APN O I PARCEL SIZE 06919 ND U9EAPPucAnoN# b <br /> OWNER Rick Townley p...209-81 0-4023 <br /> OWNER ADDRESS PD- Box CITYISTATE/ZtA 1 ri en, <br /> CONTRACTOR Purviance Driliers, Inc pO _ 3"i 54— <br /> CONTRACTOR ADDRESS PO Box 64 -7 _ CnYISTAT£IZIP Linden, CA 95 <br /> C-ST WELL DRILLING LCENSE NUMB / ,r ExPJRATIDN DATE <br /> Dr. We� wA-;" �6tAesg yt3l sot.. PHON- 6 3v- 8'"- 39s9 <br /> PERFORATION CONTRACTOR 'p a /��� /�' <br /> PERFORATION CONTRACTOR ADDRESS r� �� CITYISTATEIMP .�V 4C.4 eA- `rap to <br /> ❑ C-57 Well 0d!ling License Number ( ry�E�IRpI�d2tido 55oo to D <br /> Bureau of Alcohol,Tobacco and Firearms-Users of High Explosives License Number7� �O 'vEXpiFa'fG9 a y I <br /> CNP Hazardous Material Transportation(or EViesives License Number���-__ Espirabon Date <br /> San Joaquin County Sheriff-Coroner Explosives Application and Permit License Number ZO Z_ Expiration Cale ' <br /> California Occupational Safety Health-Blaster License Number Expiration Date � Z <br /> REAsoN Foss DGSTRUcncN ❑ Dry ❑ Replacement Well ❑ Caved In ❑ Pil Well It Inactive ❑ Test Hole <br /> Detected J Suspected Well Water Contaminants) ,ilAO>L-4— <br /> Adjacentpropertywithcontamination(Address) i>tnt.� <br /> Known Soil J Water contaminants at edlacentproperty ✓X./!u� <br /> EXISTING WELL CCNSTRUCTION DETAILS 10' Open Bchom ❑ Gravel Pack ❑ Uncased ❑ Other <br /> Well Log copy attached ❑ Yes hr No Grout Seal ❑ No ❑ Yes R below ground surface(bgs) Hote Dlameter inches <br /> Well Conductor Casing Yes WNe Depth of Conductor Casing ftbgs OiameterofCDrtductorCasing_inches <br /> Well Casing Diameter_L!�_tnrhes Total Depth R 2 it Depth to Water Fq it Depth of Casing it bgs ., <br /> DF_STAt1CT10N SPECIFIGAhTCN <br /> Sealing Material from 0 it bgs to 1400 ftbgs fillerMaterial_ from ftbgs to 1(O-0 it bgs <br /> Well casing to be perforated Icy one of the following methods: "horn fl bgs to ft bgs <br /> ❑ Mllls Knife Number of cuts every ft and I or <br /> jd Exploslves V Detonating cord R -vrithout projectile <br /> ❑ Detonating cord and boosters ❑ with pmlediles every __ft ❑ without prajectile <br /> G outer <br /> Sealing Material NeatCement(941btag/5-6gaJwater) SanclCement, sack mix 17 gal water Bentonite Pellets <br /> Bantonite(20%solids) Manufacturer Spec%solids_% Name Specs on File Specs Submitted <br /> Placement MethodPumped Free Fall Other <br /> Seal Completion Complete booth Mushroom Cap 3 ft bgs Complete to Existing Surface Pad <br /> I 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 VITTH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE�VITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> ce <br /> CONTRACTORS StDNATU - -TI DATE 3/ <br /> r ! - P Y <br /> CE/VFX <br /> r It 02 ?020 <br /> SANJOA UI <br /> . HFACTH p ETq�1'Y <br /> . i <br /> ` MENt <br /> i <br /> DEPARTMENT USE ONLY <br /> Application Accepted By �✓ Dale `�� 0 Z") Area C�C <br /> Destruction inspection By ,/� Dale Area <br /> 1D4 S <br /> COMfd NTS G e GV 10 <br /> it] e041r <br /> PE SC Received Che Amount PartniU Invoice# Well IDaY <br /> Codes Info a Remitted Date Service Request# <br /> 3'I' 1NSfsds— ITT <br /> / 7 7 WELL DESTRUCTION PERMIT <br /> EHD43-0e ( i D/ ( 2 <br /> 7 W5J07 <br /> Z-d ZSU-28607, out s-lalll.lQ eoueln.lnd d89.t-0 OZ L0 add <br />