Laserfiche WebLink
WELL DESTRUCTION PERMIT <br /> P1,10ATERSYSI'EM❑Y.�No <br /> SANJOAQUINCOIMrc ENVOtONMHi'fAL HEALTH D"wErneffNT J04EWF,BP.R Ave 3m FL-STOCMEON CA 95202-(209)/6g3J20 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES I YEAE FROM DATE ISSUED <br /> =S.ppEyp DReas A' ) cnl C,16r,471a/l 9�/Jf3 <br /> OtpSq All ^0 PARCELSITF_WNDUREAPPLICATIONq p <br /> OWNER 'J IIt /I Gr)� /y FROM <br /> corvTRAcroR�gat rr/I)/ !7f ///nn puone 9/If.�'SS1--1169 <br /> CONTRACEOR ADDREEa 3131. Q�Pi /f �.;ffr,�lPPr cu;; 1ty Lm/srATPnm�an/rho ('ardr�auc.LA g57/f2 <br /> GVWELLDw.LD+c Wcenee NMmeR //75fo EEPm.+T1aNDATe /^3l'OX <br /> PERPOE ATExacco TRACTOR PRONE <br /> PPRroRATIONCOnTItA RADDREaa CITY/FEATE2R <br /> ❑ C-57 Well Drilling Idcenu Number Expiration Date <br /> ❑ Bureau of Alwhol,Tobacco and Fireerme-Dun oflBgh EEPI.Iv. Lium.Number Fxplretion Data <br /> ❑ CRP ffaurdwr Material Troutimortioe for alloavea Li...Number Expiration Date <br /> ❑ San Joaquin County Sherif- moner EEplow.Application and Permit Li..Number ExpiraOon Data <br /> ❑ Clifamia Ooupabonl Safety Health-Bkskr License Number Expiration Data <br /> R_vgaon POR DEatRurnon ❑ Dry ❑ Replacement Well ❑ Cavedk 1071 Ht Wdl r Inactive ❑ Tel}Iole <br /> Daecled/Suspeeted Well Water Coonminunt(a) <br /> Adjacentpropertywitheonkmirbtion(Address) <br /> Known Soil/Water wntamimob at adjacent property <br /> EXISTING WELL CONNOti cnoN DerAIEs ❑ Opera [3Omvd PecR X Unceud El Other <br /> Well Logcopyatul 13Y. ❑ No Groot Seel Y.jZ_ft blow glwnd surface(bgs) Hak D'umeur ;�ch. <br /> Well Conductor Cuing 13Y. p No DeplhorCooduetor Casing ftbgs Dinmelerof Conductor Cuing cher <br /> WdlCnkg D'umeler inch. TOWDepth 10 R Depth to Water Depthof Cuing ft <br /> DESTRtICEION gPECIFlCATOIV ,rs <br /> S.liag Material from �ftbgsm /0 ftbgs Filler Matta l Rom ftbgs to ftbgs <br /> Wal uaiag to be perforated by ,of the fll rAll tram ftbgs to ftbgs <br /> ❑ Millsllinife Number ofclml Rand/m <br /> ❑ Eaplosivea ❑ Detmutngcord ❑ withpmjacTleeevery ft ❑ widrwt Pmjeelile <br /> ❑ Derontingomdamilbwatcra ❑ with Pmjxtiles every ft ❑ withodprojeotile <br /> ❑ Other <br /> Sealing Material fd Neal Cement(94Jbbag/54gufwmer) ❑ Sand Cement .sakmrs/7gl Water ❑ Bentonite Pelila <br /> ❑ Ikntimik(20%e011a) ❑ hfanufecmrer Spa%adids % Name ❑ Spasra HIe ❑ Speca Submitted <br /> Placement Method Pomped [3ree Fll E3 EA <br /> Fhtt <br /> Sal Completion Complemwith Mmhrwm Cap a ftbgs ❑ Compete to Exbdng Surface Pad <br /> 1 HEREBY CERTIFY THAT I NAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL SE DONE W ACCORDANCE WITR SAN <br /> JOAQUHi COUNTY OSENNI CE5,STATE LAWS,AND RULES AND REGULATIONS. I ALSO CERTIFY THAT M REQUIRED LICENSE IS <br /> C[IRRENT AND ACfD'E WIT11 THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> MINI M 24 H UR AD ANCE NOTICE REQUIRED FOR INSPECTIONS <br /> ComRAcrone3lcnATURE Tme�faYcJ Sc:aaT�� DATE (Z�2r�ob <br /> DEPARTMENT USE ONLY <br /> Application Accepted By Date �I Ar. /Afa <br /> D.Dumiw]nspection By Date Employ.RNI <br /> I <br /> COMMENTS <br /> PE SC Received ChmldN Amount Permid Intone If Wd11D11 <br /> Coder Info call weaftkd Data Service �v�nit0y� <br /> 1 �f OYv <br /> wdl D,ae.eioePm�� <br /> mmaxo ap <br /> 104005 <br />