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WELL D TRUCTION PERMIT ADD03' <br />NDUM RECENEEP <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE FLOOR - STOCRTON CA 952! (209) e468-3420 <br />C. <br />NON-REFUNDABLE PERMIT CALL (209 I <br />953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROMWA�E SABV06 <br />JOB ADDRESS Pombo Ranch Facility at 24100 S. Lammers Road CITY/ZIP Tracy 95376 ENVIRON MENT HEAA <br />CONTRACTOR V&W Drilling / M.J. Kloberdanz & Associates PHONE 916-777-4100 / 209 -577 -8186_' ­'_" <br />CONTRACTOR ADDRESS P.O. Box 576981, Modesto, CA (MJK&A) CITY/STATE/ZIP Modesto, CA 95357 <br />WELL WATER WITH Gasoline CONTAMINANTS. <br />ADJACENT PROPERTY AT WITH SOIL/WATER CONTAINING <br />CONTAMINANTS OF <br />WELL LOG COPY ATTACHED ❑ Yes OXNo on file a t S JDEH DIAMETER OF CONDUCTOR CASING inches <br />WELL WITH CONDUCTOR CASING ❑ Yes lid No DEPTH OF CONDUCTOR CASING ft bgs <br />I file) DI&I M <br />EK C-57 Well Drilling License Number C-57-720904 Expiration Date 4- 3 0- 0 7 <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 />WELL DESTRUCTION ❑ Open Bottom ❑ Gravel Pack ❑ Uncased EROther Monitoring Wells <br />Well Diameter 2 in Total Depth 20 & 4Oft Depth to Water -12' ft ❑ Casing to be Perforated from ft to ft <br />Sealing Material Meat Cement (94 lb bag/5-10 gal water) 13Sand Cement sack mix / 7 gal water E3Bentonite Pellets <br />❑ Bentonite (20% solids) ❑ Manufacturer Spec % solids % Name ❑ Specs on File ❑ Specs Submitted <br />Placement Method ®)Pumped ❑ Free Fall ❑ Other <br />❑ Complete with Mushroom Cap 3 ft below grade ❑ Complete to Existing Surface Pad <br />METHOD OF WELL CASING PERFORATION NA <br />Well casing to be perforated from ft bgs to ft bgs <br />❑ Mills Knife Number of cuts every ft and/or <br />❑ Explosives ❑ Detonating cord only with or without projectiles every ft <br />❑ Detonating cord and boosters with or without projectiles every ft <br />❑ Other <br />❑ Other <br />I HEREBY CERTIFY THAT I HAVE THE AUTHORITY TO COMMIT THE ACTIVITY DESCRIBED ABOVE FOR THIS CONTRACTOR, THAT I HAVE <br />PREPARED THIS APPLICATION AND THAT THE WORK WIL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE <br />LAWS, RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS CURRENT AND ACTIVE WITH THE CALIFORNIA <br />CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION LAWS. <br />MINI MLiM 24 HOLJR ADVANCE NOTICE REQUIREDFOR INSPECTIONSSIGNED 11 — _ _1 � _ TITLE S �(/ _4'� /---DATE / — I7-04; <br />—D4; <br />DEPARTMENT USE ONLY <br />Application Accepted By V1>AAACA L_ Date Z `I d Area 6 ZF ! f <br />Destruction Inspection ByLL�vtitn-ori, Date q / Z-/ Employee ID# 6z <br />COMMENTS fAn%Q0SM,i !S 4'U aft, GA1LI mWS kc, 4c,&a rfApll,, rxnndl� 4A,4 wt"(j, NQ2a`1 C21M0 <br />PE SC <br />Codes Info <br />Received <br />By <br />Check#/ <br />Cash <br />Amount Date Permit/ Invoice# <br />Remitted Service Request # <br />Well ID# <br />3-501. <br />3403 <br />EHD43-02-008 Well Destruction Permit Addendum. doe <br />3/3/2004 <br />