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MUM 48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS TITLE S irrp,t^ MI o DATE I I ) 3 - CONTRACTORS SIGNATURE DEPARTMENT USE ONL Date / gidodo Date Employee ID# A Application Accepted By Destruction Inspection By COMMENTS Area S/ej f- r t j •-• t - I I 4 .1. _ t .t ILJ. . , .,. WELL DESTRUCTION PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPT PUBLIC WATER SYSTEM 0 Ya4o 1868 East HazeIton Avenue- STOCKTON CA 95205-6232 - (209) 468-3420 1 YEAR FROM DATE ISSUED NON-REFUNDABLE VERmil ciniz,, INNAN ,.,. c. ')--S 1-1 C • irk ct._ zit . JOB ADDRESS pa 1.-. esyx.c.4.3 ,.›.--T APN 3" L 100 ° c6- PARCEL SIZE '1.41NnSE APPLICATION 0 7 CROSS STREET 9, el Q_ 41 PHONE ..0 q - ci Lci - 1 9 3-3 V \ OWNER corns k...t .. Cs 1 Lt "3 rki EfQ_--tt ik 13 Orr/STATE/ZIP rilA.T0 jr,a-C,L., CA , 1s33-ip OWNER ADDRESS 0 t /..) Ck.k- 4v- 0 : Ii% "/".'\ L"' PHONE .-(3 CI 4 ‘ 7 - 7 9 - CONTRACTOR _Alls- C -.1 CD‘CD S . K; I r... 4, •,--, CITY/STATE/ZIP 0 r c3 CA. 95 3 ,ro CONTRACTOR ADDRESS CONTRACTOR a- L, . ..,, E E NUI I 939 a-Or EXPIRATICA D7 5 - 7 - C-57 WELL DRILLING Or i cr CONTRACTOR , PliONE, 1// ri, " PERFORATION ADORE deida-N ote iTY/STATETZI PERFORATION CONTRACTOR all t License Numbe gn Da : ... Well Drilling Users High Explosives License Nunqr -0 1t tn Dr 2 f _ Bureau of Alcohol. Tobacco and Firearms - of CHP Hazardous Material Transportation for Explosives License Number _ 3 °2 6 / Expiration Da 7 Permit License Number Expiration Date San Joaquin County Sheriff-Coroner Explosives Application arid License Number Expiration Date California Occupational Safety Health - Blaster REASON FOR DESTRUCTION 0 Dry 0 Replacement Well D Caved In 0 Pit Well -2$q Inactive 0 Test Hole Contamlnant(s) N-rilt Detected I Suspected Well Water hi M Adjacent property with contamination (Address) Known Soil i Water contaminants at adjacent property_ran EXISTING WELL CONSTRUCTION DETAILS 0 Open Bottom N., ,Gravel Pack 0 Uncased 0 Other 0 Yes ft below grcund surface (bgs: Hole Diameter t,./ -IA Inches Well Log copy attached 0 Yes j11, No Grout Seal 0 No _ No Depth of Conductor Casing ft bgs Diameter of Conductor Casing Iv It, inches Well Conductor Casing 0 Yes -PI( Total Depth 1 I 0 ft Depth to Water I 3 ft Depth of Casing Li 0 ft bgs Well Casing Diameter 1 -Ice inches Ob•ltRt brio. SFE(IFICATION I Material from I IC) ft bgs to 0 ft bgs Filler Material tj I 321 frorn ft bgs to ft tigl Sealing to be by one of the followina methods: from ft bgs to ft bgs Well casing perforated 0 Mills Knife Number of cuts every ft and i or ExplosivesDetonating cord 74 with projectiles every I 0 ft 0 without projectile -1Q y, 0 Detonating cord and boosters 0 with projectiles every ft 0 without projectile Nt 0 Other _ Material Neat Cement 94 lb bag / 5-6 gal water) Sand Cement i 411 .3. sack mix /7 gal water Bentosittlic751,3 Sealing Spec % solids % Name Specs on File Specs Su A Bentonite (20% sollasT ufacturer Free Fell Other /IPA L iR Placement Method um t .7 Seal Completion Complete with Mushroom Cap — ft bgs Complete to Existing Surface Pad 7.../ I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WiLL BE DONE IN ALIUKL)WNLC nylir, awl'. JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE UCENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION LAWS. PE SC Codes Info Received B Check/ Cash Amount Remitted Date Permit/ Service Request 4 Invoice # Well IDA q.'S 01 1E- 1 41 4 - .,1-- *3i;1S- 11.2 3-W 6>t/ 1/7o3s-002— WELL DESTRUCTION PERMIT END 43-08 43-08 revised 4/14/18