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Application Accepted By <br />Destruction Inspection By <br />COMMENTS <br />,DEPARTMENT USE <br />Date <br />Date <br />WELL DESTRUCTION PERMIT <br />PUBUC WATER SYSTEM D Yes El No <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPT 1868 East Hamilton Avenue -STocaToN CA 95205-6232 - (209)468-3420 <br />NON-REFUNDABLE PERMIT <br /> <br />GALL 20 953-7697 FOR IN <br />JOB ADDRESS i_ ‘,_... (31:2.1.s 41 ,go 9A-41(.4 c,Ty,z,, L.444.rop . _._ , <br />CROSS STREET 5 it DJ • APH"'Y.( ID — t ut PARCEL SEE IR ,7 LAND USE APPIJCATION # <br />OWNER Duke Realty, attn Ryan Marshall PHONE (510) 719 0243 <br />OWNER ADORES 200 Spectrum Center Drive, Suite 1600 cirrisTATErap Irvine, CA 92618 <br />CONTRACTOR titiNetr I—Le. PHONE 69.) .31/6 trtilt,f X. 15.1....0 <br />CONTRACTOR ADDRESS 2.I' r1 si-)rs_ ciTy/sTATEmp Elba- P It ck_emalo <br />C-67 WELL DRILUNG LICENSE NUMBER I 0444e4 C E xpliaAnoN DATE .Q., I 0 frh . I PERFORATION CONTRACTOR kJ 1 P PHONE <br />PERFORATION CONTRACTOR ADDRESS C1TYrSTATEMP <br />0 C-57 Well Drilling License Number Expiration Date <br />Bureau of Alcohol, Tobacco and Firearms - Users of High Explosives License Number Expiration Date <br />CHP Hazardous Material Transportation for Explosives License Number Expiration Date <br />San Joaquin County Sheriff-Coroner Explosives Application and Permit License Number Expiration Date <br />California Occupational Safety Health - Blaster License Number Expiration Date <br />REASON FOR DESTRUCTION El Dry 0 Replacement Well CI Caved in 0 Pit Well inactive CI Test Hole <br />Detected / Suspected Well Water Contaminant(s) <br />Adjacent property with contamination (Address) <br />Known Soil / Water contaminants at adjacent property <br />EXISTING WELL CONSTRUCTION DETAILS '5E( Open Bottom 0 Grand Pack 0 uncased 0 Other Ciltiebie .ipp ( Cr04A <br />Well Log copy attathed 0 Yes t.io Grout Seal )4( No 0 Yes ft below ground surface (bgs) Hole Diameter inches <br />Well Conductor Casing Oies No Depth of Conductor Casing ft ups Diameter of Com:lector Casing inches <br />Well Casing Diameter Inches Total Depth liC) It Depth to Water i..I.,-_ ft Depth of Casing i 0 ft bgs <br />VONT /awl ION SPLEIHI -A rum .,.$ $ (r . <br />1- <br /> <br />2.-:Acif- k Sealing Material from 0 ft bgs to t 0 . ft bgs Filler Material <br />? <br />zt,,L1- from ft bgs to 12,C) It bgs 2, <br />Well casing to be perforaterl by one of the following methods: 1,J _Lk from It bgs to ft bgs <br />0 Mills Knife Number of cuts every It and / or <br />0 Explosives 0 Detonating cord 0 with projectiles every _ _ ft 0 without projeclile <br /> <br />O Detonating cord and boosters 0 with projectiles every ft 0 without projectile <br />0 Other <br />Sealing Material VIV'eat Cement (94 lb bag 1 5-8 wa Sand Cement sac* mix / 7 gal water Bentonite Pellets <br />Bentonite (20%eolith+ r) Spec %solids % Name Specs on File Specs Submitted <br />Other Placement Meth V od Pumped W <br />j <br />Free F..111 i . <br />Seal Completion Complete with Mus room 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 />CONTRACTORS SIGNATURE <br />A...Ail UM 48 HOUR ADVANCE NC)TICE REQUIRED FOR INSPECTIONS tc <br />LP 04 0 kiALIC kit Tina V11114\ Ct_Datalaikktiagt <br />1 % <br />.114 A44,6101,gyNiC 4Z <br />PAyik oefl-evr ..ove <br />441? n 2 „A <br />sly JaiQui 4u21 <br />iis.,47rizRoA4c0uNne <br />Area <br />-2)1r 1,l Employee ID* <br />ONLY , <br />PE <br />Codes <br />SC <br />Info <br />Received (MIAOW <br />Cash <br />Amount <br />Remitted Date Permit! <br />eft, e Request* Invoice* Well ID* <br />L1373 4, i <br />Lk <br />CF1-(2 1 / '-5-'- .*).2.--74 4V6041144)( <br />EHD 43-08 <br />revised 4/14/18 <br />WELL DESTRUCTION PERMIT