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JOB ADDRESS 5 (60 NI , [2-61. cmdzip WitiNtr,c,a. Oa 1533i <br />CROSS STREET P 1 i / / APN 22(0-0\DO- 010 PARCEL SIZE ',7 ' LAND USE APPLICATION # <br />OWNER ber440W WN PHONE .201. tpol, go11 <br />OWNER ADDRESS Fi '111) 1\11W CITY/STATE/ZIP Wik•Ackit) ("A 6tur)--7 <br />CONTRACTOR NU cit RiS DrIIIIN3 i NO PHONE 2061- 52_2‘112-e, <br />CONTRACTOR ADDRESS \CI ii\De 12-c 1)15i... CITY/STATE/ZIP NI Dacia Go) 1 -?g--7 <br />y,.. C-57 WELL DRILLING LICENSE NUMBER unu2:2- EXPIRATION DATE Di' .,30 • 2,02-1 <br />PERFORATION CONTRACTOR PHONE <br />PERFORATION CONTRACTOR ADDRESS CITY/STATE/ZIP <br />0 C-57 Well Drilling License Number Expiration Date <br />0 Bureau of Alcohol, Tobacco and Firearms - Users of High Explosives License Number Expiration Date <br />0 CHP Hazardous Material Transportation for Explosives License Number Expiration Date <br />0 San Joaquin County Sheriff-Coroner Explosives Application and Permit License Number Expiration Date <br />0 California Occupational Safety Health - Blaster License Number Expiration Date <br />REASON FOR DESTRUCTION Dry 0 Replacement Well 0 Caved In 0 Pit Well 0 Inactive 0 Test Hole <br />Detected/Suspected Well Wat r ontamlnant(s) <br />Adjacent property with contamination (Address) <br />Known Solt/Water contaminants at adjacent property <br />EXISTING WELL CONSTRUCTION DETAILS 0 Open Bottom X Gravel Pack 0 Uncased 0 Other <br />Well Log copy attached 0 Yes )ilf No Grout Seal 0 No 0 Yes ft below ground surface (bgs) Hole Diameter inches <br />Well Conductor Casing 0 Yes 0 No Depth of ConAu5.4por Casing It Diameter of Conductor Casing inches <br />Well Casing Diameter \.0- inches Total Depth i/V ft Depth to Water M ft Depth of Casing ft bgs, <br />DESTRUCTION SPECIFICATION A <br />Sealing Material from V ft bgs to IA ft bgs Filler Material from ft bgs to ft bgs <br />Well casing to be perforated, by one of the following methods: from ft bgs to ft bgs <br />0 Mills Knife Number of cuts every ft and/or <br />0 Explosives 0 Detonating cord 0 with projectiles every ft 0 without projectile <br />0 Detonating cord and boosters 0 with projectiles every ft 0 without projectile <br />0 Other <br />Seating Material i • Neat Cement (94 lb bag/5-6 gal water) Sand Cement sack mix/7 gal water Bentonite Pellets <br />i Bentonite (20% solids) .1 Manufacturer Spec % solids_ % Name L Specs on File i Specs Submitted _ <br />Placement Method - Pumped i Free F Other <br />Seal Completion I Complete with Mushroom Cap 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 I AM IN COMPLIANCE WITH ALL <br />WORKERS COMPENSATION LAWS. <br />SIMUM /49.HOU7/11:„WANCE NOTICE REQUIRED FOR INSPECTIONS <br />CONTRACTORS SIGNATURE TITLEVV'k \\/(11 DATE \ <br />WELL DESTRUCTION PERMIT <br />PUBUC WATER SYSTEM El Yes 0 No <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 East HazeIton Avenue - STOCKTON CA 95205 - (209)468-3420 <br />NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />mm om mm..ammom IIIIIIII m 1 III livin Anwpwriammoomm .__._._M ____• a mmomm mummiummumm <br />m mu r ommmmkrmayiemn. muimmirmicummaammom IN IIIIIIIIIIIIIIIIIIII 1111111111iMMININIIIIIIMMIN 11111111111111111111=LEAllimmall01111111.11111111111111111111 NM= MIIIIIIIIMINIIMMINIIIII 11111111111111irmiiiiimrara ,t_.________•111 <br />01111041p11 IIIIMMN 1101511111111111: 4 <br />gill ...m.m. ummummi mr.--- NI _ !!!...11•11111111111111.1.1111111111..1111111ril <br />I1111111111111111111111111111111111111111111111=11111111111111 <br /> <br /> 1•111101111111111111111111111111111EMMIIIMMINIMI11 <br />IIIIIIIIIIIIIIIII 1111111111111111111 MUM IIIM III a MIIIMM MI - m, <br />1111111111 1111111 II 11111 MEW <br /> <br />IP ., <br />DEPARTMENT USE ONLY <br />Application Accepted By Date //d Area <br />Destruction Inspection By '.....1\Ltirt rijk‘c t*/ £-t&L Date 24 qi toi Employee ID* AS- <br />COMMENTS Lit' r (y 13r f See) at: 1,4 1) oC , < I cif r YPc I Ch ;1Ce <br />PE <br />Codas <br />SC <br />Info <br />Receivre Checket <br />',Cash <br />Amount <br />Remitted Date Permit/ <br />, 1 Service Request I Invoice I Well IDS <br />,i3a 06c) V, 4,,_--- ,Osd 1-1q12.1 jpfotit1i(1y52-- :SS7311UOV aLIS WELL DESTRUCTION PERMIT <br />/2,06716.,2D <br />EHO 43.08