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i1 <br /> WELL DESTRUCTION PERMIT <br /> PUBLIC WATER SYSTEM ❑Yes ❑No <br /> SAN JOAOVIN COUNTY ENvelON ENTAL HEALTH DEPARTMENT I S"East Haxelton Avenue-STOCKTON CA 95205-(209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> y <br /> Joe ADOREas Mu 1W crrY/IIP <br /> Crass STREET APN QPARCELS�.j(f&MN/O USE <br /> /ATPtPAl1 TTIONf gO <br /> OWNER PHONE /�v�l �IW'"1116 `fi 11A <br /> OWNER ADDRESS CITYISTATEMP <br /> CONTRACTOR I Yl i r`M1/ PHONE —�T�61N <br /> CONTRACTOR ADW.n PrIH(Sfd- CRY/STATFJZWM"tO.GA 1 <br /> C-57 WELL Dsit.Lm LICENSE NUMBER ExPIRATION DATE <br /> PERFORATION CONTRACTOR PHONE <br /> PERFORATION CONTRACTOR Mons CrrY/STATE(ZIP <br /> O C-57 Wei DrlHkng License Number Expiration Date <br /> ❑ Bureau of Alcohol,Tobacco and FIrearms-Users of High Explosives License Number Expiration Date <br /> ❑ CHIP Hazardous Material Tra sportabon lot Explosives License Number Expiration Dale <br /> ❑ San Joaquin County Stwd11-Coroner Explosives Application and Permit License Number Expiration Dale <br /> ❑ California Occupational Safety Health-Blaster License Number Expiration Dale <br /> REASON FOR DEMUMM Dry ❑ Replacement Well ❑ Caved In ❑ Pit Well ❑ Inactive ❑ Test Hole <br /> Detected(Suspecled Wen Water teminant(s) <br /> Adjacent property with contamMetlon(Address) <br /> Known Soi/Waler comtamirtarnb at adjacent property <br /> ❑ Open Bottom ❑ Gravel Pads O U ncased ❑ Other <br /> Well Leg copy attached ❑ Yes ❑ No Grout Saw ❑ No ❑ Yes_ it below grand surface(bgs) Hols Diameter lodes <br /> Well Cornductor Casing❑ es ❑ No instil of Condpdor Casing If¢Qt Diameter of Conductor Casing MId»s <br /> won Casing DIaNNelef intros Total Depth It Depth to Weld fl Depth of Casing It bgs. <br /> Sealing Material from —fl logs to _h logs Filler Material from It logs to If logs <br /> Well cesing to be meted by one of the fanotetna methods: from R bgs to If bgs <br /> ❑ Mlns Knife Number of cuts every it andlor <br /> ❑ Explosives❑ Delorrottng cord ❑ with projectiles every It ❑ without projectile <br /> ❑ Detonating cord and boosters ❑ with projectiles every if ❑ without prgectile <br /> ❑ Other <br /> Material I Neat Cement(94®bay5-6 gal water) Sand Cement sack rrdx/7 gat water Bentonite Pellets <br /> Bentonite(20%s)ids) U Manufacturer Spec%sdids_% Name L Specs on File Specs Submitted <br /> Placement Method X Pumped :I Free Fail I Omer <br /> Seal Completionto with Mushroom Cap it bgs t 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 1 AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> IMUM Xi UZkDX ANC2E NOTICE REQUIRED FOR IN PECTIONS <br /> CONTRACTORS SKMATURIE �/_ TRLaDATE •I •� <br /> _ r-- LW <br /> - -I 202, <br /> USN <br /> q coaCNrY <br /> Ep RTMENT USE ON Y n� <br /> Application AxaPlad BY Date Aran !� <br /> Destruction Inspection By Date Employee I <br /> COMMENTS ' P L Io ILO ( �ti� O <br /> PE Sc Received Chedcf/ Amount Date PerrnW Invoice a Well IDS QJ <br /> fo Cash Remitted a f J� <br /> D t . <br /> WELL DESTRUCTION PERMIT <br /> _fJ332,2-1 7D <br />