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- --- •-- - . —......... ................ .—p•u "b...., I I cmri urtLimit L/R I C unnutu <br />JOB ADDRESS :3451- N,IYNirrli <br />1 <br />an ri-Nrif cmdzip 1-1)0K-toN ,.,'' A c1521 5 <br />CROSS STREET ' i . . -1-* APN 1 - 0 -1S1) PARCEL SIZE Q I LAND USE APPLiCATION a <br />OWNER CiAll .d a ltR PHONE 21:11- vog-- 44-US .-kiap <br />OwNER ADDRESS 349+ N kilf1.2)1(r) 'ail a. CITY/STATE/ZIP StOCLKtthi rOt. (152. ir..7 <br />CONTRACTOR fY1A ct ilc Irrk11 PHONE 2oci 522_ IV- <br />CONTRACTOR ADDRESS 1 <br />i <br />1 n \ ps. <br />ACIL <br />crwsTATE,z,p ili tD. 'A lis.5--/ ik C-57 WELL DRILLING IJCENSE NUMBER <br />PERFORATION CONTRACTOR <br />q10KU2:2— EXPIRATION DATE <br />PHONE <br />PERFORATION CONTRACTOR ADDRESS CITY/STATE/ZIP <br />0 C-57 Well Drilling <br />0 Bureau of Alcohol, Tobacco and Firearms • <br />0 CHP Hazardous Material Transportation for <br />0 San Joaquin County Sheriff-Coroner Explosives <br />0 California Occupational Safety Health • Blaster <br />License Number Expiration Date <br />Users of High Explosives License Number Expiration Date <br />Explosives License Number Expiration Date <br />Application and Permit License Number Expiration Date <br />License Number Expiration Date <br />REASON FOR DESTRUCTION 1 Dry 0 Replacement Ke Well 0 Caved In 0 Pit Well 0 Inactive 0 Test Hole <br />Detected/Suspected Well Water ontaminant(s) <br />Adjacent property with contamination (Address) <br />Known Soil/Water contaminants at adjacent property <br />EXISTING WELL CONSTRUCTION DETAILS 0 Open Bottom 114, Gravel Pack 0 Uncased 0 Other <br />Well Log copy attached 0 Yes )iir No Grout <br />Well Conductor Casing 0 Yes 0 No Depth <br />Well Casing Dlametet V inches Total <br />Seal 0 NO 0 Yes It below ground surface (Ns) Hole Diameter inches <br />of Condtctor Casing It Diameter of Conductor Casing inches <br />Depth ft Depth to Water ft Depth of Casing ft bgs . <br />DESTRUCTION SPECIFICATION <br />ft bgs Filler Material from ft bgs to ft bgs Sealing Material from U ft bgs to <br />Well casing lobe perforated by one of the followino methods; from ft bgs to ft bgs <br />0 Mills Knife Number of cuts every ft and/or <br />0 Explosives 0 Detonating cord <br /> <br />0 Detonating cord and boosters <br />0 Other <br />0 with projectiles every ft 0 without projectile <br />0 with projectiles every ft 0 without projectile <br />Sealing Material ' ' Neat Cement (94 lb bag/5-6 <br />.<" Bentonite (20% solids) 11 Manufacturer <br />Placement Method Pumped <br />Seal Completion Complete with Mushroom <br />gal water) , Sand Cement sack mix/7 gal water Bentonite Pellets <br />Spec % solids__ % Name Specs on File Specs Submitted _ <br />- Free Fall - Other <br />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 />JOAOUIN 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. ief3 MINIMUM )4. HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br />CONTRACTORS SIGNATURE T1.011"r rink b‘414)tri,ATE oi 24 7.1 <br />4-ry-132.. <br />Date <br />DEPARTMENT USE ONLY <br />Date 3 .7s.dl Application Accepted By <br />Destruction Inspection By <br />COMMENTS f, <br />r <br />Area LI/ci'i <br />Employee ID, DA <br />I f Of' ToviSi <br />s-l ALi,Jo <br />F—Rei:;vv/P-Q . _ 1111111111 _ --_,7/10 0 <br />WELL DESTRUCTION PERMIT <br />Pueuc WATER SYSTEM 0 Yes 0 No <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 East HazeIton Avenue - STOCKTON CA 95205 - (209)468-3420 <br />NON-REFUNDABLE PERMIT <br />PE <br />Codes <br />SC <br />Into <br />Received <br />B <br />Checkl/ <br />Cash <br />Amount <br />Remitted Date Permit/ <br />Service Request # Invoice # Well ID! <br />Vi ,545---- 4/ (-IL: 5 IS 24 N VCO Li 1 g (E1 I <br /> <br />53L0 — .71 /2-Z6, 6/ 7 WELL DESTRUCTION PERMIT <br />