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Application Accepted By Destruction Inspection By COMMENTS -Th e he r 10r of file et:op-is Org* i.-Ji ii fYI; }It re, e )th If-PL 41V1. Ct"Cdh/ Date Date , er e..../J• • • DEPARTMENT USE ONLY /7•7 ‘)C, /Yea L//99 44174 Employee IDM lied to eliwonai-e any obstro:lieS, I trcivfes. sand eereent 0 , ? 5c9 Lk r terlitaz 6 41,voi? Li r.A.t. I f7/( WELL DESTRUCTION PERMIT PUBUC WATER SYSTEM 0 Yes AND SAN JOAOUIN COUNTY ENVIRONMENTAL HEALTH DEPT 1868 East Hamilton Avenue -Sfocurosi CA 952054232 - (209) 488-3420 NON-REFUNDABLE PERMIT CALL 209) 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED ..loa Aboime 5 r 1" CROSS STREET 1111WW. Owtout VEIWOISErdiree OWNER ADDRESS ON3(1 CONTRACTOR C.C.A futi G1. r Dr: . CoNTRACTOR ADDRESS C.:60 5, K; I ro t, 2)1-1e4 C47 WELL DR4LuNO LICENSE NUMBER 4 c4 PERFORATION CONTRACTOR 1,4 PERFORATION CONTRACTOR AOORESS NI A CTTY/Dll CS PARCEL SIZE / • LAND DON I S. Nora CrrvISTATE/Zim Nowa LK S 31(14 CrTY/STATIV7JF a EXPIRATION DATE 31 - as) PHONE Cm/STATE/Zia .04000 A „,118 C-57 Well DuRing Bureau of Alcohol, Tobacco and Firearms - Users of High Explosives CHP Hazardous Material Transportation for Explosives San Joaquin County Sheriff-Coroner Explosives Application and Permit California Occupational Safety Health - Blaster 8.15L2B126.12IERM9B Dry yit Replacement Wet Detected / Suspected Well W r Inant(s) ft Adjacent proportystm contitmlnatbn (Address) P)/ e.3 446) Known Soil / Water contaminants at adjacent property (1\ DIETING WELL CONSTRUCTION DETALLI 0 Open Bottom Well Log copy attached 0 Yes 0 No Grout Seal C No Well Conductor Casing 0 Yes O No Depth of Con Well Casing Diameter Inch*. Total Depth License Number Expiration Date License Number Expiration Date License Number Expiration Date License Number Expiration Date jo.: PA YMEN 1.. License Number Expiration Date Pit Well 0 Inactive 0 Test Hole ! 1 eceive„Di tiN 1 1 2020 JOA /1r/40N co, inches H DEp4WV,TAL 9 / me- lt bps r NT Caved In Gravel Pact Uncased 0 Other Yes It below ground surface lege] Hole Diameter Casing Ft bg(04.: ft Diameter of Conductor Casing It Depth to Water Depth of Casing ....t^sb •te% Sealing Material from 0 It bgs to v—m- ft bgs Filler Material c. _ . .. , . _ from CI ft bgs to C. (5 ft Doi Well casing to be gegigtisj by one of the followlna methods; from It bgs to It bgs Mills Knife Number of cuts every II and lot Explosives 0 Detonating cord 0 With projectiles every ft 0 without projectile 0 Detonating cord end boosters 0 with projectiles away If o without projectile Other Sealing Material eat Bentonite (20% • solids_ Placement Method • Pumped Fre rnrail Seal Completion ComplotaTr)1rilushroom Cap Sand Cement Name • ft bgs sack mix I 7 gal water Bentonite Pellets )cSirims on File poem subnnA n ck. rt/ te 0, *iv to Existing Surface Pad C_ONf DESTRUCTIoN SPErifiCATIoN I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPUCATX)N AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS. AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE HI CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPUANCE WITH ALL WORKERS COMPENSATION LAWS. m 48 UR ADVANCE NOTICE REQUIRED FOR INSPECTIONS CONTRACTORS SIGNATURE TM.E Or- DATE aCI I PE Codes SC Info Received JI,m, Cheat" Cash V Ahiount Remitted Permit/ Sarit unt ili Invoice a Well IDS t/73 161 ao- iii6ez_. sigs- (p17ki toaitTa69 EHD 4108 revised 4/14/18 WELL DESTRUCTION PERMIT