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WELL DESTRUCTION PERMIT ��// <br /> / \'4 C 11 *� PUBLIC WATER SYSTEM F-1Yesly-No <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPT 1868 East Hazelton Avenue-STOCKTON CA 95205-6232 -(209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 2C .i3-7697 FOR(NSPECTKNtS EXPIRES'I YEAR FROM DATE ISSUED <br /> JOOVjB A�DDRESS335 •v O•• G Crrym., aC"r"cpyq 96$50 <br /> 5380 1 <br /> CROSS STREET PARCEL SIZEAND USESAPPPLICATION#Z4I4OJ// <br /> N `kvT LL PHONE20Q-�4O - /=5— <br /> O.&AXAmny' S."L, CITY/STATE/ZIP F1 1)952-1t1:3 <br /> CONTRACTOR ` <br /> PHONE O -!545- 11135 <br /> CONTRACTOR ADDRESSIntl p� CITY/STATEIZIP C.S C S <br /> C-57 WELL DRILLING LICENSE NUMBER `y E 1 EXPIRATION DATE "$ � �' 2-2- <br /> PERFORATION CONTRACTOR PHONE <br /> PERFORATION CONTRACTOR ADDRESS CITY/STATEIZIPp A <br /> C-57 Well Drilling License Number�C, ipL 1 "') Expiration Dale J� <br /> Bureau of Alcohol,Tobacco and Firearms-Users of High Explosives License Number Expiration Date <br /> CHP Hazardous Material Transportation for Explosives License Number Expiration Date <br /> San Joaquin County Sheriff-Coroner Explosives Application and Permit License Number Expiration Date <br /> California Occupational Safety Health-Blaster License Number Expiration Date <br /> REASON FOR DESTRUCTION ❑ Dry ❑ Replacement Well ❑ Caved In ❑ Pit Well Inactive ❑ Test Hole <br /> Detected/Suspected Well Water Contaminant(s) <br /> Adjacent property with contamination(Address) <br /> Known Soil/Water contaminants at adjacent property <br /> EASTING WELL CONSTRUCTION D AI S ❑ Open Bottom ❑ Gravel Pack ❑ Uncased ❑ Other <br /> Well Log copy attached ❑ Yes No Grout Seal ❑ Nu ❑ Yes it below ground surface(bgs) Hole Diameter inches <br /> Well Conductor Casing❑ es No Depth of Cond to C Ing ft bgs Diameter of Conductor Casing inches <br /> Well Casing DiameteriM ,inches Total Deptl y Depth to Water ft Depth of Casing ft bgs <br /> DE.STRGC710S SPECIFICATION <br /> Sealing Material from ­Q_ft bgs to ft bgs Filler Material from ft bgs to__ft bps <br /> Well casing to be perforated by one of theJallowing methods: from ft bgs to it bgs <br /> ❑ Mills Knife N er of cuts every ft and I or <br /> ❑ Explosives❑ Delo cord ❑ with projectiles every it ❑ without projectile <br /> onating cord and boosters ❑ with projectiles every ft ❑ without projectile <br /> ❑ Other _-- <br /> Sealing Material Neat Cement(94 Ib bag/5-6 gaf water) Sand Cement sack mix/7 gal water Bentonite Pellets <br /> XBentonite(20%solids) facturer Spec%solids_° Name Specs on File Specs Submitted <br /> Placement Method Pumped Free Fall Other <br /> Seat Completion Complete ushroom Cap it 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 /> JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. 1 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 /> °'NIMUM 24 HOUR ADVANCE NOTICE REC' <br /> CONTRACTORS SIGNATURE ` VITLE , �/ r 1'• • DATE <br /> If <br /> PA, <br /> —I jby� <br /> ��!. fill <br /> UjNFCLI pMNOT U <br /> NT'ly <br /> — T. <br /> I <br /> I <br /> EP T ENT USE ONL <br /> Application Accepted By Date I Area <br /> Destruction Inspectio 8 D e Employee ID# <br /> COMMENTS I G- 1' K <br /> PE Sc Received Check#/ Amount at Permit/ Invoice# Well IDS <br /> Codes Info Remitted Service Request# <br /> EHD 43-08 WELL DESTRUCTION PERMIT <br /> 10/5101 <br />