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,x.. tom€ a <br />WELL DESTRUCTION PERMIT IPUElLICWATER SYSTEM [3 Yes [3 No <br />SAN JoAoulm CouNTY ENNgtpttYf3NT'I�L NEALTI D[PART1aENT <br />1668 East Haselton Avenue - STocuToN CA 95205 - (209) 468-3420 <br />..... manor taS3A111197 FOR INSPECTIONS EXPIRES 1 YEARfItOM DATE ISSUED <br />� 1i.�iiR� mrd <br />OWNER ADDI <br />Sea n •v LA4P USE APPLICATION y <br />CONTfMCToR ADDREsa 14 �n D'7 <br />EXPIRATION DA <br />Well casing to be perforated by one of the following methods: <br />1 c57 WELL DIaLLWO LICENSE NUMBER i {� <br />PHS <br />PERFORATION CONTRACTOR <br />CaV/STATEM <br />❑ Detonating cord and boosters O With projectiles every <br />PERFORATION COUMCTDR ADDRESS <br />LICen98 Number �� <br />Expiration Date <br />❑ C57 Well Drilling <br />User of High Explosives <br />License Number __- <br />Expiration Date <br />❑ Bureau of Alcohol. Tobacco and Firearms <br />License Number <br />License <br />Expiration Date <br />❑ CHP Hazardous MatedelTmnsportabon for E.P,.,.. <br />Application and Permit <br />License Number �— <br />Expiration Dale <br />❑ San Joaquin County Shodff'Coroner Explosives <br />License Number <br />EXP If8U0f1 pfll8 <br />❑ GalilorNa OrxsrPatlanal Safety Health -Blaster <br />❑ Caved In ❑ Ph Well ❑ Inactive ❑ Test Hot. <br />DEYTRUCiION Dry -... ❑ 'Replacement Well <br />REASON FOR <br />DeteFted/Suspected Well We Contnminant(s) <br />MINIMUM'S OUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br />Adjacent property with contamination (Address) <br />Known SolilWater contaminants at adjacent property <br />FXISTVtO WELL CONSTRUCTION DETAILS ❑ Open Bottom ❑ Gravel Pack ❑ Uncased <br />❑ Other <br />Well Log copy attached ❑ .Yea ❑ No Grout Sul ❑ No ❑ yes_ <br />h below ground surface (bgs) <br />Hole Diameter Indies <br />Well Conductor Casing❑ ❑ No Depth of Conduct r Casing <br />M <br />h s Diameter of Conductor Casing Inches <br />Depth Casing it bgs <br />Well Casing Dlametstinches Total Depth It Depth to <br />Water it <br />of <br />DESTRUCTION bl`ECWNATfQrd r(� I <br />Sealing Material from �_If bgs to �!-,L_ It bgs Filler Material <br />from It bgs to it bgs <br />Well casing to be perforated by one of the following methods: <br />from it bgs to it bgs <br />❑ Mills Knife Number of cuts every h and/or <br />❑ Explosives Detonating cord ❑ with projectiles every <br />It ❑ without projectile <br />❑ Detonating cord and boosters O With projectiles every <br />it ❑ without projectile <br />❑ Oltlw <br />SnOng Material n Neat Cement (94 lb ba0-6gal wafer) FI Sand Cement <br />sack mlxrr gal water n Bentonite Pellets <br />Bentonite (20% solids) ❑ Manufacturer Spec % solids_% Name <br />❑ Specs on File Ll Specs Submitted <br />Placement Method n Pumped n Free Fell , n Other <br />Seal Completion Complete with Mushroom Cap It bgs D <br />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. <br />I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br />CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD <br />AND THAT I AM IN COMPLIANCE WITH ALL <br />W15kiihS COMPENSATION` LAWS. <br />MINIMUM'S OUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br />CGIITRACTORS <br />Application Accepted By <br />Destruction Inspection By <br />COMMENTS <br />TMENT USE r <br />Dale 1 <br />Date 114riployse [DO <br />PE SC Reeeivsd Check Amount PermlV <br />Cods I o sh ernitted Qate Service Rs user e . ; Invoice fk Ws11.IDg <br />Ill I <br />ii. _ A _ .ria , I w. 11. 1 1 lr%/ I I 1 i a 1 <br />EHO 48-06 ! / rJ WELL DESTRUCTION PERMIT <br />