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f <br /> ` I! <br /> WELL DESTRUCTION PERMIT <br /> PUBLIC WATER SYSTEM ❑Yes ❑% <br /> SAN JOAOUN COU uTV ENVIRoumENTAL HEALTH DE PARTMEUT 1868 East Hozaiton Avenue-SToctctort CA 95205-(209)46"20 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 OR INSPECTIONS EXPIRES 1 YEAR FRDM DATE ISSUED <br /> y <br /> JOB ADDRESS CniYMP <br /> CROSS STREET APN _ PARCELS¢P LAND USE APPLICATION I <br /> a <br /> r141 k <br /> OVINER p' PHONE <br /> OWNER ADDRESST/ CRY/STATEZP <br /> CONPHONE— 911C ftI111N INCH -0 IN 4. 7 ' Z <br /> CON'rRACTOR ADDRESS 1161 gS CTTY/STATFILP <br /> 7 <br /> y!y{ C-57 WELL DRILLMG L10ETt5E NUNDER EXPIRATON DATE v <br /> PER'FO`RATION CONTRACTOR PHONE <br /> PERFORA-noN Co TTLACTOR ADDRESS CTrY/STATE/ZIP <br /> ❑ 057 Well Ddlling Llconse Number Expiration Dale <br /> ❑ Bureau of Alcohol.Tobacco and Firearms-Users of High Explosives License Number Ecplrallon Data <br /> ❑ CHP Hazardous Material Transportation for Explosives License Number Eeplratlon Dale <br /> ❑ San Joaquin County Shedll-Coroner Explosives Appricatlon and Permit License Number Explrallon Date <br /> ❑ Callfomla Occupallonal Salary Health-Blaster Ucenso Number Explrallon Data <br /> REASON FOR DESTRUCTiONDry ❑ Replacement Well ❑ Caved In ❑ Plt Well ❑ Inactive ❑ Test Hole <br /> Oeteclod/Suspocled Well Water ontamin ent(e) <br /> Adjacent properly vvlth contamination(Address) <br /> Known Soll/Waler contaminants at adjacent property <br /> Extsm+a WELL COtminucTION DETAn-5 ❑ Opon Bcllt—omm ❑ Gravel Pack ❑ Uncasod ❑ Other <br /> %va"Lag capy atmcned 1:1 Yes � ea <br /> NO . Grout Sl �( No ❑ Yes II below ground surface(bgs) Holo Diameter Inches <br /> Well Conductor Caoin9❑ Yes No Depth of Conductor Casing it bcls Diameter of Conductor Casing Inches <br /> Well Casing Olnmahi n ladles Total Depth'1V t II Dap1h to Water _.II Depth of Casing It bps <br /> ESTRUCTIONSPE FICAON y►/� / <br /> Sealing Meterlol fro �1 eft bgs to�_It bgs Filter Material from it bgs to R bgs <br /> Well casing to be perforated by ono of the following methods: from it bgs to it bgs <br /> ❑ Mills Knife Numberotcuts ovaryIl and/or <br /> ❑ Explosives❑ Detonating cord ❑ with projectiles every it ❑ wdtilout projectile <br /> ❑ Detonating cord and boosters ❑ with projectiles every It ❑ Without projectile <br /> ❑ Other <br /> Sea 11 g Materlal r• Neet Cement(9a Ib beg/a-G gal water)n Send Cament sack mixn gal water n Bentonite Pellets <br /> Bentonlle(20%so do) U Manufacturer Spec%sollds_% Name O Specs on File ❑ Specs Submitted <br /> P oca Tient Method A Pumped n Free Fall1 n O er <br /> Seat Completion Complete with Mushroom Cap j it 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 WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT 1 AAI IN COAIPUANCE WTTH ALL <br /> WORKERS COMPENSATION LAWS. <br /> MI IMI O VANCE NOTICE REQUIRE 11tfyC1{OAI,p(yhl�N PECTIONS <br /> C014TFLACTORS SIGNATURE T '\1'�V 1 <br /> II I qN L I I I I41,I <br /> I I <br /> 971_ — <br /> i <br /> l <br /> N� 7), <br /> .j- ji <br /> DEPARTMENT USE ONLY - <br /> Application Accepted By Date a3 aO�d Area <br /> Destruction Inspection By Date Employee IDN <br /> COMMENTS <br /> PE SC Rerolved Cheeks/ Amaunt PermlU <br /> Codes Into 8 Cash Remitted oats Service Re uest N lnvolc.I Wall ION <br /> y34cFo /sa `>J o0 0� <br /> WELL DESTRUCTION PERMIT <br />