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WELL DESTRUCTION PERMIT I'ullur,Wnnarsr.irm I Ives []NO SuiJonnumCournYEuAnduLlenlnllfPAlnlDrvr 18GnLasI11,11 I Avenue SIOCKTONCA9520S6232-(209)468-3420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Joe ADDRESS 51� /�rayM ry„e I�rl} e 1 �07 Crrv(ZrP a 5 a CROSS STREETVAr"` VM 1 •V1 {ALA APPI W1 Ci D' 11+� PARCEL SCI,ZE'lq LAND USE APPLICATION a e OWNER rab i F��1 r r- p y11v ` PHONE OWNER ADDRESS ✓ 1 V• • {y/��,�+ 1 CITY/STAATTERI//P]]_ET CONTRACTOR r�ll�I1 1 PHONE 1553- '352' IZZ� CONTRACTOR ADORESS CCO l CITY/STATE/ZIP Sgl7gcr, CIA q;w6 C-57 WELL DRILLING LICENSE NUMBER EXPIRATION DATE ,al)zo2o PERFORATION CONTRACTOR PHONE PERFORATION CONTRACTOR ADDRESS CITYISTATE/ZIP ❑ C-57 Well Drilling License Plumber Expiration Date Bureau of Alcohol,Tobacco and Firearms-Users of High Explosivas License Number Expiration Date CHP Hazardous Material Transportation for Explosives License Number Expiration Date San Joaquin County Sheriff-Coroner Explosives Application and Permil License Number Expiration Dale California Occupational Safely Health-Blaster License Number Expiration Dale REASON FOR DESTRUCTION ❑ Dry Replacement Well O Caved In ❑ Pit Well jig Inactive ❑ Test Hole Detecled/Suspected Well Water Contaminant(s) Ad)aceul property With contamination(Address) Known Soil/Water contaminants at adjacent property EXISTING WELL CONSTRUCTION DETAILS ❑ Open Boll— ❑ Gravel Pack ❑ Unased ❑ Other Well Log copy allached O Yes ❑ No Grout Seal ❑ No ❑ Yes_ ..1t below ground surface(bgs) Hole Diameter___ _inches Well Conductor Casing 11) Yes O No Depth of Conductor Casing ft bgs Diameter of Conductor Casing inches Weil Casing Dlamster�inches Total Depth h Depth to Water R Depth of Casing_ It bgs DESTRUCTION SPECIFICATION Seating Material fromO RC sto 2b ftbgs Filler Material Ir 11 YD GKfm�� R bs to-w A de b g Well casing to be perforated by one of the following methods: Ntq- from N1W II bgs to S46 it bgs ❑ Mills Knife Number of cuts every ft and/or ❑ Explosives❑ Detonating cord ❑ With projectiles every R ❑ without projectile ❑ Detonating cord and boosters ❑ With projectiles every R ❑ without projectile ❑ Other Sealing Material Neat Cement(94/b Dagl5-6 gal wafer) Sand Cement 1013_sack mix/7 gal water Bentonite Pallets Bentonite(20%solids) Manufacturer Spec%solids H Name Specs on File Specs Submitted Placement Method romp. Free Fall Other Seal Completion ComplIT11—MIT17ushroorn Cap S It bps Complete to Existing Surface Pad i I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. 1 ALSO CERTIFY THAT MY REQUIRED LICENSE IS CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION LAWS. IINIMUM 48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTT�19Nry_S CONTRACTORS SIGNATUREVlql TRLE6Up roll& rdMl7 DATE 11-2-112,02-0 A Ali All-AtI(IM-i I I I T' h _ Fti�. I �y f� DEPARTMENT USE ON, v 10 Application Accepted By `"� S DMS I<^ Area �J�•� Destruction Inspection By ag� DSI. $�C f1rltC: Employee IDM r IC COMMENTS PE Sc Received Check#/ Amount Date PermlU Invoice M wall 10# Codes Info Cash Remitted Service Re uesI M EHD d 411 ///y2— WELL DESTRUCTION PERMIT revised1/11118