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WlmbJ- DESTRUCTION PERMIT <br /> 19,JBLIC WATER SYSTEM E]Yes� No <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEAL'rn DEPARTMENT 304 E WEBER AVE 3""FLOOR-STOCKTON CA 95202 - (209))46688.-3420 <br /> NON-REFUNDABLE PERMIT LAIA,(2 9)953-7697 FOR INSPECTIONS EXPIRES I YEAR F-ROM DATE ISSUED <br /> LA <br /> JOB ADDRE.S crry/zll' 2 <br /> L. > <br /> OWNER PHONE 0 <br /> OWNER fn(j <br /> IDD SCITY/STATE/LIP <br /> '.- <br /> S <br /> CONTRACTOR <br /> —PIION 2 <br /> 7 <br /> / <br /> CON— CTOK ADORES CITY/STME/ZIP <br /> C-57 WELL DRILLING LICESE NUMB'R U.01" EXPIRATION DATE <br /> A <br /> PERFORATION CONTRACTOR ;af"/, J PHONE 4, <br /> PERFORATION CONTRACTOR ADDRESS c. CITY/STATI <br /> ,2---C-57 Well Drilling License Number 4-0 J&e Expiration t <br /> • Bureau ol'Alcohol,Tobacco and Firearms-Users of High Explosives License Number Expiration Date <br /> • CI-IP 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 /> 4 <br /> REASON FOR DESTRUCTION LR [)ry [] Replacement Well E] Caved In 0 Pit Well E] Inactive ❑ Test I-Ioie <br /> Detected/Suspected Well Water Contaminanl(s): <br /> Adjacent property with contamination (Address): <br /> Known Soil/Water contaminants at adjacent property: <br /> EXISTING WELL CONSTRUCTION DETAILS [T-Open Bottom 0 Gravel Pack 0 Uncased 0 Other <br /> Well Log copy attached 0 Yes Grout Seal 0 No 11 Yes 11 below ground surface(bgs) Hole Diameter inches <br /> Well Conductor Casing 0 Yes � No Depth of Conductor Casing tl bgs Diameter of Conductor Casing inches <br /> Well Casing Diameter inches Total Depth ft Depth to Water ft Depth of Casingft bgs Z <br /> DESTRUCTION i"— <br /> SPECIFICATION -4—rd <br /> Scaling Material from ft bgs to s Filler Material from ft bgs to ft bgs V1j <br /> from ft bgs to _ft bgs <br /> Mills ifeP N---Number of cuts every ft and/or I—, <br /> 0 with projectiles every ft 0 without projectile <br /> ❑ Detonating cord and boosters: 0 with projectiles ever ft 0 without projectile <br /> 0 Other b j <br /> Scaling Material Nes ement(94 lb bag/5-6 gal watel) I Sa Cc[ ent Sack mix/7 gal water 0 Bentonite Pellets <br /> % <br /> 0 Bentonite(204olldsp� Manufacturer <br /> anu fcturer Spec%solids <br /> 0 N e 0 Specs on File 0 Specs Submitted <br /> Placement Method,, p d 0 Free Fall 0 t t er <br /> 1 <br /> Seal Completion: mplete with Mushroom Cap —ft bgs 0 Complete to Existing Surface Pad <br /> I HEREBY CERTIFY HAT 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. Z> <br /> MINIM M RADVANCE NOTICE REQUIRED FOR I SPECTIONS <br /> CONTRACTORS SIGNATURE: r DATE:lCh/A <br /> Z V <br /> ,141V <br /> '34N'lo �006 <br /> ��,qj 71?0 /V <br /> 4 <br /> llzpgtv 1VI I, <br /> DEPARTMENT USE ONLY <br /> Application Accepted By I Date A;cc.' <br /> Destruction Inspection By Date Employee I P# <br /> COMMENTS $s <br /> PE SIC Received Chec Amount Date Permit/eInvoice# Well ID# <br /> Codes Info B Cash Remitted Service Re nest <br /> q3 LA 2-S <br /> HID 4)-02-008 Well Destruction Pci-r-1 Addendum 41,04 Ic tX.()4 <br /> W7,04 <br />