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19; 2014 7 ; 45AM canvvcLLouFSTRUCTION PERMIT No, 8884 P. 2 <br /> PUBLIC WATER SYSTEM 0 Yes ❑No <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 600 E MAIN STREET-STOCKTON CA 85202 - (209)46"20 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> Joe ADDRESS 15-n 110",-fLrt A K. CITY/ZIP <br /> CROSS STREETAPN_ Z D� 'Y5b,�' PARCEL SIZE — LAND USE APPLICATION <br /> OWNER �✓�Ify ��plv�/� Y lo�)�I�/7tr�4 n TCL PHONE gVZ, --Zi.4' t� <br /> OWNER ADDREss g9q�!Vt <br /> oc, N (prT.�•��t1 �,r Yt/Z U/{ JI,� }e �(� CITY/STATFJZIP Y/ <br /> CONTRACTOR � PHONECONTRACTOR ADDRESS t0 fM/yYt,-,-z �ay CITY/STATE/ZIP 4 '(a <br /> C-57 WELL DRILLING LICENSE NUMBER l EXPIRATION DATE <br /> PERFORATION CONTRACTOR PHONE � <br /> PERPORATION CONTRACTOR ADDRESS CITY/STATE/ZIP — ENVIRONMENTA1 WRAITI <br /> C-57 Well Drilling License Number Expi1RWt�FR1l1Y'Pc' <br /> C❑ Bureau or Alcohol,Tobacco and Firearms-Users of High Explosives= License Number Expiration Date <br /> r <br /> ❑ CHP Hazardous Material Transportation for Explosives License Number i F Expiration Date <br /> ❑ San Joaquin County Sheriff-Coroner Explosives Appiication`andPartni6 Uoense Number L–,~ Expiration Date <br /> ❑ Califomla Occupational Safety Health-Blaster ,,.Lwfgnse Nu, b r! Expiration Date <br /> REASON FOR DESTRUCTION ❑ Dry ❑ Replacemgn�WWlgl, ( Pit W II _ ❑ Inactive Test Hole <br /> Llbing'� f2ei: cRnspst.. d <br /> Detected/Suspected well Water Contaminant(s) 1� <br /> Adjacent property with contamination(Address <br /> Known Soil/Water contaminants at adjacent property <br /> EXISTING WELL CONSTRUCTION DETAILS ❑ Open Bottom ❑ Gravel Pack ❑ Uncased ❑ Other <br /> Well Log copy attached ❑ Yes ❑ No Grout Seal ❑ No ❑ Yes ft below ground surface(bgs) Hole Diameter inches <br /> Well Conductor Casing ❑ Yes ❑ No Depth of Conductor Casing it bgs Diameter of Conductor Casing Inches <br /> Well easing Diameter inches Total Depth ft Depth to Water ft Depth of Casing ft bgs <br /> QESTRUCTION-SPECIFICATION ' <br /> Sealing Material from�tb6—ft bgs to^S_ft bgs Fllier Material P[.C,c '� from G�C� ft bgs to fhgs <br /> Well casing to be oerforated by one of the following methods: from ft bgs to ft b s <br /> ❑ Mills Knife Number of cuts every ft and/or <br /> ❑ Explosives ❑ Detonating cord ❑ with projectiles everyR ❑ without projectile <br /> ❑ Detonating cord and boosters ❑ with projectiles everyft ❑ without projectile <br /> ❑ Other_ <br /> Sealing Material 0 Neat Cement(94 lb bag/5-6 gal Water)❑ Sand Cement sack m/x/7 gal water ❑ Bentonite Pellets <br /> Bentonite(20%solids) 0 Manufacturer Spec%solids % Name 0 Specs on File ❑ Specs Submitted <br /> Placement Method Pumped 0 Free Fall U Other <br /> Seal Completion ❑ Complete with Mushroom Cap 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 WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> MINIMUM :7-,VANCE NOTICE REQUIRED FOR INSP CTIONSCONTRACTORSSIGNATURETITLE i DATE <br /> , <br /> -P E, <br /> i <br /> MI <br /> fl, fit <br /> V <br /> PAYMENT' <br /> px�.r6d.v�vilhdd �� 1VE �P 1 <br /> ' I _.. S 2 <br /> R 9 01, <br /> o k betnU cQfrpidted car inspe,s�'_ t. p 1 9 2.014 <br /> 'by? C►�V MLr� a1 H��i i, ilYisiI ►�' <br /> ENVIRONMEN)� <br /> ' PER <br /> AI HEAl71;; <br /> JOAQUIN N <br /> ' - cou Tv . MIT%6ERVICE3 <br /> SAN <br /> I ENVIROMENTAL <br /> i HEALTH DEPARTMENT <br /> DEPARTMENT USE ONLY <br /> Application Accepted By � ' l���'� Date �� { Area fl� _tel <br /> Destruction Inspection By Date Employee ID$$ /aaa } <br /> COMMENTS 16 C it flS i i ✓ L 4L <br /> PE Sc Received Check#/ Amount Permit/Codes Info B Cash Remitted Date Service Re uest# Invoice# Well IDft <br /> Re'ce _v- ed Time Sep, 19, 2014 7 ; 54AM No, 7086 WELL DESTRUCTION PERMIT <br />