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WELL DESTRUCTION PERMIT <br />PUBLIC WATER SYSTEM ❑ Yea o No <br />SAN JOAQUN COUNTY ENVIRONMENTAL HEALTH DEPT 166E East Hazelton Avenue - STOCKTON CA 95205-6232 - (209) 46ill <br />NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />JOE ADo tns / Q a S- j aA k yY U^ <br />CnyrZvCROS <br />a <br />r�, <br />I c !, n L_ <br />STREET / IV ST— APN IL `"/ I L�� _PARCEL SIZE y'`LAND USE APPLICATION R <br />o <br />DINNER <br />oWNER�' 1 ren s PHONE g1S��J�t — -313t,q <br />r 7 <br />OWNER ADOR I I CITY/STATElLP ROW SQ V! r J E r OA 1 �1GFJ I <br />CONTRACTOR PHONE 916 - 3Ff3 3 C 3 iG <br />CONTRACTOR ADDRESS CRY/STATEMP �SQZ <br />C-57 WELL DRiLuNa �1 t <br />NumaR_(QQ.Qt7 (- EXPIRATION DATE �� J0 _ ..Z 1 <br />�LICEME <br />PERFORATION CONTRACTOR SUVA- <br />rAt PHONE l <br />PERF_OR/ CONTRACTOR ADDRESS CrrY/STATEMP <br />hT C-57 Well Drilling License Number Ezpiratlon Data �� f <br />Bureau of Alcohol, Tobacco and Firearms - Users of High Explosives License Number Expiration Date <br />CNP Hazardous Material Transportation for Explosives License Number Expiration Date <br />San Joaquin County ShwW-Coroner Explosives Application and Perrnit License Number Expiration Date <br />Caltlomia Occupational Safety Health - Blaster Lic Number Expiration Date <br />ReAa EM DESTRUCTION ❑ Dry ❑ Replacement Wal ❑ Caved In ❑ Pit W4 cUva ❑ Tart Hole <br />Defaced / Suspected Wag Water ContamInant(s) A/ ITN z <br />Adjacent property with eontominstlon (Address) Nf,4 <br />Known Soil / Water contaminants at adjacent property <br />EMPNG WELL CONITNSIC710N DETAS-• /iS Open BoEorn ❑ Gravel Pack ❑ Uncesed ❑ Other <br />Wolf Log copy attached ❑ Yasr No Grout Seal ❑ No ❑ Yes_ ft below ground surface (bgs) Hole Dhwwter tubs <br />Well Conductor Casing ❑ Yes ❑ No Depth of Conductor Casing R tors Diameter of Conductor Casing InchesW-11 Casing Dlamelsr­-J�_tuhas Total Depth <br />ft Depth to Water :5 3 <br />_JjR Depth of Casing R bgs <br />nrxra u"r'rON SP CR[CATION <br />Sealing Material from a fl bgs to 5— ft bps Filler Material <br />from ft bgs to R bgs <br />Well cytng to be by orm of the Mowing In from ft bgs to ft bgs <br />EMllls <br />Knife a Number of cuts every R and / or <br />❑ Explosives ❑ Detonating cord ❑ with projectiles every R ❑ without projectile <br />Detonating cord and boosters ❑ with projectiles every R ❑ without projectile <br />❑ Other <br />Sealing Material Neat Cement941b /5-6 <br />( bap gal water) >f' Sand Cement sack m/x l7 gel water BsrrtonHs Pellet <br />Bantonite (20% soN Juror Spec % solids_% Name Specs on File Specs Submitted <br />Placement MethodUmpetl Free Fell Other <br />Seal Completion Com Ushroom Cap -5 Rs Complete ornplete 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. 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 />t7Mntr:714CE NOTICE REQUIRED FOR INSPECTIONS <br />CONTRACTORS SIGNATURETITLE 'I'I(],✓ I -11L 1 DATE <br />DEPARTMENT USE ONLY <br />Application Accepted By GL Date IIS I Area O/ 7 <br />Destruction Inspsdbn By - M Data L - \ Employee 10# <br />COMMENTS J 1 - <br />J �1A/l�i1, ^t7 -41(i �'iIiGL IIAL ), r <br />em�D�i.'�■►/��E��ml�mll�►�l.'��i�� <br />EHD 43-0b r <br />WELL DESTRUCTION PER <br />messed 4/11118 MR <br />