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JOB ADDRESS i 110 ill 44,11 OT117-1PJZ4 IONJA_15.12_____ <br />CROSS STREETWUINIA IIVE4 Ap N 2.0G. 019. PARCEL SIZE 0 - LAND USE APPLICATION 4 <br />OWNER 11 I„MinTS <br />OWNER ADDRESS P' <br />h i t ,if 1, ,, 14A PHONE qV.. 55 1"0 <br />0 -woukIxt.1 • , CrrY/STATFJZte tSuot ON. Go, giq 4x. <br />CONTRACTOR til ,_:PHoNE 2041• 41.2,14 244 <br />CONTRACTOR ADDRESS CITY/STATE/ZIP <br />C-57 WELL DRILLING LICENSE <br />PERFORATION CONTRACTOR <br />NUMBER UV 11 .1-2.-- EXPIRATION DATE 011% ..?O• 202-1 <br />PHONE <br />PERFORATION CONTRACTOR ADDRESS <br />0 C-57 Well Drilling <br />0 Bureau of Alcohol, Tobacco <br />0 CHP Hazardous Material Transportation <br />0 San Joaquin County Sheriff-Coroner <br />0 California Occupational Safety <br />Cm/STATE/Le <br />License Number Expiration Date <br />and Firearms - Users of High Explosives License Number Expiration Date <br />for Explosives License Number Expiration Date <br />Explosives Application and Permit License Number Expiration Date <br />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 Wal(Contarninant(s) <br />Adjacent property with contamination <br />Known Soil/Water contaminants <br />(Address) <br />at adjacent property <br />EXISTING WELL CONSTRUCTION DETAIL* 0 Open Bottom )(Gravel Pack 0 Uncased 0 Other <br />Well Log copy attached 0 Yes <br />Well Conductor Casing 0 Yes <br />Well Casing Diameter VI inches <br />0 No Grout Seal 0 No 0 Yes ft below ground surface (bgs) Hole Diameter inches <br />0 No Depth or Conductor Casing ft VI._ Diameter of Conductor Casing inches <br />Total Depth WO It Depth to Water 0 ri Depth of Casing ft bgs . <br />PESTRUMON SPECIFICATION n <br />ft bgs to V 0 ft bgs Filler Material from ft bgs to ft bgs Sealing Material from V <br />Well casing to be perforated by pne of the followino methods: from tt bgs to ft bgs <br />0 Mills Knife Number of cuts every It and/or <br />0 Explosives 0 Detonating <br />0 Detonating <br />0 Other <br />cord 0 with projectiles every fl 0 without projectile <br />cord and boosters 0 with projectiles every ft 0 without projectile <br />Staling Material : ' Neat Cement <br />i Bentonite (20% solids) 11 <br />Placement Method 7 Pumped <br />Seal Completion ys-Elerinpl iete-w <br />(94 lb bag15-6 gal water) Sand Cement sack mix/7 gal water i Bentonite Pellets <br />Manufacturer Spec % solids % Name L Specs on File Specs Submitted <br />n Free Fall ,„„4 7 Other <br />ith MI tA Dem es,' 4t bgs V Complete to Existing Surface Pad <br />- <br />/44 <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 />i f9 <br />MINIMUM )4.HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br />CONTRACTORS SIGNATURE S•4s4d'r n71E1)0141 W DATE 0'i -03 24 <br />45111141111111• <br /> 11111111111111111 4 IMIMMUMAI 111111111111111WWW...MINIIIIIIIIMMIG <br />11111116111111111111111111111111111111 ........... .............. <br />ON <br />/14 P,41 <br />WELL DESTRUCTION PERMIT <br />PUBLIC WATER SYSTEM El Yes El No <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1888 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 />DEPARTMENT USE ONLY <br />Application Accepted By L' Z— Dale <br />Destruction Inspection By /*CS e2r71"— <br />COMMENTS <br />PE <br />Codes <br />SC <br />Info <br />Received <br />Ety,ii.; <br />Check*! Amount <br />Remitted Date . ,. <br />Permit/ Invoice I/ Well ID, <br />i 4 l : , (:) 3 ati.it vro ittyl <br />—4 rl , <br />Area 4 /q <br />Date V- 2- 3 - 2--/ Employee ID# <br />END 43-08 — WELL DESTRUCTION PERMIT