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OWNER ADDRESS 17.1,40 'Zile 56 12e <br />CONTRACTOR <br />CONTRACTOR ADDRESS PO 60 X 12 <br />C-57 WELL DRILLING LICENSE NUMBER Ion <br />PERFORATION CONTRACTOR <br />WELL DESTRUCTION PERMIT <br />PUBLIC WATER SYSTEM 0 Yes 0 No <br />SAN JoAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />NON -REFUNDABLE PERMIT CALL (209) 953-7697 <br />CROSS STREET .4(11-0.5 A ue APN 225 110 <br />OWNER ..iN61)EV IVA Ar2)4 <br />PERFORATION CONTRACTOR ADDRESS <br />1868 East Hazelton Avenue - SiockToN CA 95205 - (209) 468-3420 <br />FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />CITY/ZIP -e,e 00 o6 3 toc. <br />PARCEL SIZE i 7•WILAND USE APPLICATION # <br />PHONE 2 oq - - e0.989 <br />CITY/STATE/ZIP po,-) e-e). q53 <br />PHONE 7e.-)et 772. - 757 <br />CITY/STATE/ZIP V 14 U e 6,(14,0 e4- 4574-z <br />EXPIRATION DATE - <br />PHONE <br />CITY/STATE/ZIP <br />JOB ADDRESS 1551 iu JAcki-opve RA <br /> <br />C-57 Well Drilling <br />Bureau of Alcohol, Tobacco and Firearms - Users of High Explosives <br />CHP Hazardous Material Transportation for Explosives <br />San Joaquin County Sheriff-Coroner Explosives Application and Permit <br />California Occupational Safety Health - Blaster <br />License Number Expiration Date <br />License Number Expiration Date <br />License Number Expiration Date <br />License Number Expiration Date <br />License Number Expiration Date <br /> <br />REASON FOR DESTRUCTION 0 Dry El Replacement Well 0 Caved In El Pit Well Inactive 0 Test Hole <br />Detected/Suspected Well Water Contaminant(s) <br />Adjacent property with contamination (Address) <br />Known SoiINVater contaminants at adjacent property <br />EXISTING WELL CONSTRUCTION DETAILS 0 Open Bottom 0 Gravel Pack 0 Uncased 0 Other <br />Well Log copy attached 0 Yes pit No Grout Seal 0 No 0 Yes ft below ground surface (bgs) Hole Diameter inches <br />Well Conductor Casing 0 Yes me No Depth of Conductor Casing ft bgs Diameter of Conductor Casing inches <br />Well Casing Diameter ti inches Total Depth 5'q ft Depth to Water 3 7 ft Depth of Casing ft bgs <br />Complete to Existing Surface Pad <br />Explosives 0 Detonating cord 0 with projectiles every <br />0 Detonating cord and boosters 0 with projectiles every <br />Other <br />Neat Cement (94 lb bag/5-6 gal water) I Sand Cement <br />Name <br />Placement Method Pumped Free Fall <br />Seal Completion )c. Complete with Mushroom Cap 5 ft bgs <br /> ft bgs <br />ft boAym <br />RECEI <br />X BentorMAR 30 <br />sP"LLIVDACIIINOUNTY IRONME TmAL ENT HEALTH DEPAR <br />DESTRUCTION SPECIFICATION /e>. • iefe.ssees+g- <br />Sealing Material from 3 <br />ft bgs to 5 ft bgs Filler Material from 5- ft bgs to <br />Well casing to be perforated by one of the following methods: from ft bgs to <br />Mills Knife Number of cuts every ft and/or <br />ft O without projectile <br />ft O without projectile <br />/0-5 sack mix/7 gal water <br />Specs on File <br />Sealing Material Pellets <br />Bentonite (20% solids) Manufacturer Spec % solids <br />Other <br />NT <br />ED <br />022 <br />MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS, CALL (209) 953-7697 FOR INSPECTI NS <br />Application Accepted By <br />Destruction Inspection B <br />COMMENTS <br />1,4/ <br /> <br />DEP”TMENT USE QNL/ <br /> Date 3' _rofro Area <br />Date gl),_ Employee ID# <br />C-t-T <br /> <br />PE <br />Codes <br />SC <br />Info <br />Received <br />By <br />Check#/ <br />cash <br />Amount <br />Remitted <br />Permit/ iDate 1 Invoice # Well ID# <br />(lot pcii vi,sA, t °I 5- <br />Service Reauest4 <br />9)1/)°I" U0f004-1. <br />, I <br />EHD 43-08 <br /> -4- g o <br />WELL DESTRUCTION PERMIT <br />11/23/21