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WELL DESTRUCTION PERMIT Adjacent property with contamination (Address; Known Soii"Water contaminants at adjacent property - 0 roperty_❑ Open• Bonor-, ('travel Pack _--- ❑ 'Jrcased ❑ Giller Well Log cagy attached ❑ Yes ❑ No Grout Seal G Nr, ❑ Yes ft helow gror,nd su d'e ;hgsj Hole Diameter Well Conductor Casing ❑ Yrs ❑ No Depth of Conductor Casing f - Inches Well Casing Diameter inches Total Depth _) 8 - i, Depth to Water �6 r - � Drameter of Conductor Casing "--hes_ ---- _ ? Depth of Casing ft bgs DESTRL1Crtnrf Roc�rn.•w�,..., _ '�----- �--- Sealing Material franc '0 - it bgs to -_ Q _ft Lgs Filler Material ,t Well casing to be ---- r-- c f? bgs to. _. _R by orb of t!b follow o methods: from h egS to I Mills Knife Number of cuts every i Explosives a Detonating cord ❑ with - project+les every it _- � without projectile O Detonating cord and boosters El wRh projectiles ever, i. G Othef v without projectile Sealin Material Neat Cement (9416 bagr5-8 ga! water) Sand Cement / Paliets� sack mix,-, gel water V Sentonite Benton(te (209e sol(ds) Manufacturer Spec % sones D"O % Name Ci•vo�fi, ,Lit p F Placement Method �% umped Free Fall Specs on Fiie Specs Sutxnrt!ed Sea! Completion Complete uehroom Ca 5 Other P - rt b9s Ccmpiele to Existing Surface pad MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS, CALL (209) 953-7697 FOR INSPECTIONS DEPARTMENT USE ON Y App+zahon Accepted' By /I Z_ Date 3/�/ Destnlctian Inspection B � Area ® Employee IDI/ COMMENTS C:It f� f PS't C►.l r7Yh YYl� l In { ) r � �-♦_.ie�.11f'Qi� GI'rC i�.I iY1LuY bU�l�t('� ENO 43-05 11 FAM � I!:3 S SlH4.1, ri -i • , Invoice # 1 VhN ID! WELL DESTRUCTION PERMIT PUBLIC WATER SYSTEM ❑ Yas LSI ND SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1888 East Hazelton Avenue - STOCKTON CA 95205 - (209)468-3420 PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED FNON-REFUNDABLE T JOS •YlDRESS t J� -Firm Ili R(�1. J G TY/IJP i CROSS STREET LAI Dili '0 4 r t{ J4(, j 0517—PARCEL Q _ �.,1.� APN _;j SLZE —LAND USE APPLICATION At_ OWNER PHONE/} OWNER ADDRESS / 53 f pr !j-------- /'r?cA 9.5:"(O ! f -- CITYISTAT;;.P CONTRACTOR - M Q„ 1., vJ PHONE •aO�--`--e-+� ' r CONT TOR ADDRESS O� --- — _-CITYISTATErZIP_FuC- C. C-57 WELL DRILLING LICENSE NUMSER - EXPMtA17pN DATE S j PERFORATION CONTRACTOR j_J /A PHONE PERFORATK)N CONTRACTOR ADDRESS CITYISTATErZW C C-57 V✓eA Drilling L I License Number C Bureau of Alcohol Tobacco and F;rearms - Users of Hr n Explosives g P License Numr Expiration Data �D ❑ CHP Hazardous Material Transportation for Explosives--"—�-- License Nurroer ❑ -- A Expiration pate �� San Joaquin County Sheriff -Coroner Explosives Apoticatw and Permit license Number Expiration to C Gafdomla Occupational Safety Health - Blaster Expiration, a �O h1VrR0 ;41EN ---- License Number - Expiratio N JN Ty — RE�>30N FOR DESTRUCTh^.il ❑ Dry G Replacement Well ❑ Coved In ❑ Pit Well DetectedrSuspeCtOC Wall Water Contaminant's) I�nacbve ❑ Test Hole L r Adjacent property with contamination (Address; Known Soii"Water contaminants at adjacent property - 0 roperty_❑ Open• Bonor-, ('travel Pack _--- ❑ 'Jrcased ❑ Giller Well Log cagy attached ❑ Yes ❑ No Grout Seal G Nr, ❑ Yes ft helow gror,nd su d'e ;hgsj Hole Diameter Well Conductor Casing ❑ Yrs ❑ No Depth of Conductor Casing f - Inches Well Casing Diameter inches Total Depth _) 8 - i, Depth to Water �6 r - � Drameter of Conductor Casing "--hes_ ---- _ ? Depth of Casing ft bgs DESTRL1Crtnrf Roc�rn.•w�,..., _ '�----- �--- Sealing Material franc '0 - it bgs to -_ Q _ft Lgs Filler Material ,t Well casing to be ---- r-- c f? bgs to. _. _R by orb of t!b follow o methods: from h egS to I Mills Knife Number of cuts every i Explosives a Detonating cord ❑ with - project+les every it _- � without projectile O Detonating cord and boosters El wRh projectiles ever, i. G Othef v without projectile Sealin Material Neat Cement (9416 bagr5-8 ga! water) Sand Cement / Paliets� sack mix,-, gel water V Sentonite Benton(te (209e sol(ds) Manufacturer Spec % sones D"O % Name Ci•vo�fi, ,Lit p F Placement Method �% umped Free Fall Specs on Fiie Specs Sutxnrt!ed Sea! Completion Complete uehroom Ca 5 Other P - rt b9s Ccmpiele to Existing Surface pad MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS, CALL (209) 953-7697 FOR INSPECTIONS DEPARTMENT USE ON Y App+zahon Accepted' By /I Z_ Date 3/�/ Destnlctian Inspection B � Area ® Employee IDI/ COMMENTS C:It f� f PS't C►.l r7Yh YYl� l In { ) r � �-♦_.ie�.11f'Qi� GI'rC i�.I iY1LuY bU�l�t('� ENO 43-05 11 FAM � I!:3 S SlH4.1, ri -i • , Invoice # 1 VhN ID! WELL DESTRUCTION PERMIT