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WE33 DESTRUCTION PERMIT Test }ole PUBLIC WATER SYSTEM ❑Yes X No SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPT 1868 East Hazelton Avenue-STocKToN CA 95205-6232-1209)4689420 NON-REFUNDABLE PERMIT 353-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESSQW!I • C r Cm/ZIP it-0,C�( CROSS STREETS. (meq Lt n A C. APN 2-Sr*-I�?.D O 3 PARCEL SIZE LAND USE APPLICATION tf OWNERLane— PHONE 6\2 -1 u AS OWNER ADDRESS In ✓♦ CITY/STATE/ZIP !�C��•( bbbiii CONTRACTOR l, rj ^ 1\ PHONE -11952 p L y,, pl,'J-7`7 CONTRACTOR ADDRESS 1,1%0. �.. CL �. 1 CITY/STATE/ZIPM('�C11 C- T{J �yI,,,6N C-57 WELL DRILLING LICENSE NUMBER�Q 8`3 EXPIRATION PERFORATION CONTRACTOR PHONE I PERFORATION CONTRACTOR ADDRESS CITY/STATE/ZIP q� G57 Well Drilling License Number Q Expiration Date 'v Bureau of Alcohol,Tobacco and Firearms-Users of High Explosives License Number Expiration Date CHP Hazardous Material Transportation for Explosives License Number Expiration Date San Joaquin County Sheriff-Coroner Explosives Application and Permit License Number Expiration Date California Occupational Safety Health-Blaster License Number Expiration 52te REASON Fog DESTRUCTION ❑ Dry ❑ Replacement Well ❑ Caved In ❑ Pit Well ❑ InactiveTest Hole Detected/Suspected Well Water Contaminantls) Adjacent property with contamination(Address) Known Soil/Water contaminants at adjacent property ExISTING WELL CONSTRUCTION TAI ❑ Open Bottom ❑ Gravel Pack ❑ Uncased ❑ Other Well Log copy attached ❑ Yes No Grout Seal ❑ No ElYes ft below ground surface(bgs) Hole Diameter _inches Well Conductor Casing❑ Yes No Depth of Conductor Casing ft bgs Diameter of Conductor Casing inches Well Casing Diameter nches Total Depth-IJA-ft Depth to Water it Depth of Casing it bgs DES IRCCTIOY SPECIFICATION Sealing Material from bgs to 10n ^n ft bgs Fllier Material N a�!�[ f ldt hom 100 ft bgs to U O ftbgs Well casing to be perforated by one of the followina methods: from ft bgs to it bgs ❑ Mills Knife Number of cuts every ft and/or ❑ Explosives❑ Detonating cord ❑ with projectiles every It ❑ without projectile ❑ Detonating cord and boosters ❑ With projectiles every it ❑ without projectile ❑ Other Seg Material Neat Cement 1941b bag/5-6 gal water) Sand Cement sack mix 17 gal water Bentonite Pellets XBentonite(20%solids) Manufacturer Spec%solids_% Name Specs on File Specs Submitted Placement Method solids) Free Fall Other Seal Completion Complete with Mushroom Cap ft bgs Complete to Existing Surface Pad 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 1 AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION LAWS. MINIMUM 24 HOUR ADVANCE NOTICE REQU RED FOR INSPECTIONS ��J� CONTRACTORS SIGNATURE T'�fl lE fir r V ��DATE _L '1(r1-(r/ _ AYNjENp ECFT I AR1y ?OZ1 8AN J - -- - -- — QU1NC — --- — - -- - -- - NEALTH ONME OUN7Y - - - - - - -- — - - - - EP.4RAL TI7 NT � DEPARTMENT USE ONLY _ Application Accepted 8y � �� Date �y Area S Destruction Inspection By rX Date Employee ID# COMMENTS r I 0 c' I n f P o lo til I S PE SC Received he Amount PerPermit/ Invoice# _ Well IDN Codes Info ash Remitted ate Service Request N 3`73 1,;;J EHD 43-08 WELL DESTRUCTION PERMIT 10/5/07