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NIS <br />Q1 �� <br />WEADESTRUCTION PERMIT AIENDUM <br />JUL 13 2004 <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE 3"° FLOOR - STOCKTON CA 95202 - (209) 468-3420 <br />NON-REFUNDABLE PERMIT CALL (209) 953-7697 FOR INSPECTIONS EXPIRES 1 YEAS mo@PM6NIsi"LTH <br />JOB ADDRESS 9999 S. Austin Road CITY/ZIP 95336 PERMIT/SERVICES <br />CONTRACTOR Thp Riagpnpci c Grniip PHONE (626) 965-0911 <br />CONTRACTOR ADDRESS 2210 S. AznGa Avpntlp CM/STATE/ZIP West Covina, CA 91792 <br />WELL WATER WITH Landfill Gas Extraction Well CONTAMINANTS. <br />ADJACENT PROPERTY AT WITH SOILIWATER CONTAINING <br />CONTAMINANTS OF uu. <br />WELT. LOG COPY ATTACHED 4J Yes ❑ No DIAMETER OF CONDUCTOR CASING 3 inches <br />WELL WITH CONDUCTOR CASING 10 Yes ❑ No <br />LICENSE <br />11 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 />DEPTH OF CONDUCTOR CASING —30 ft bgs <br />License Number 753872 Expiration Date 9/30/04 <br />License Number <br />Expiration Date <br />License Number <br />Expiration Date <br />License Number <br />Expiration Date <br />License Number <br />Expiration Date <br />WELL DESTRUCTION 10 Open Bottom ❑ Gravel Pack ❑ Uncased g Other See attached Detail <br />Well Diameter 8 in Total Depth 30 ft Depth to Water 40 t + ft ❑ Casing to be Perforated from ft to ft <br />Sealing Material ❑ Neat Cement (94 lb bag / 5-10 gal water) ❑ Sand Cement sack mix / 7 gal water M Bentonite Pellets <br />❑ Bentonite (201/9 solids) ❑ Manufacturer Spec % solids % Name ❑ Specs on File ❑ Specs Submitted <br />Placement Method ❑ Pumped 11 Free Fall ❑ Other <br />b Complete with Mushroom Cap 5 t ft below grade IN Complete to Existing Surface Pad <br />METHOD OF WELL CASING PERFORATION <br />Well casing to be perforated from ft bgs to <br />❑ Mills Knife Number of cuts every _ <br />ft bgs <br />ft and/or <br />❑ Explosives ❑ Detonating cord only with or without projectiles every ft <br />❑ Detonating cord and boosters with or without projectiles every <br />❑ Other <br />❑ Other <br />ft <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 />111INIMUb 14 HOUR ADVANCE NOTICE RRJJEQUIRED /FOR <br />INSPECTIONS ! // <br />SIGNED TITLE _/�//%/.�1 �i/LILt' 1/L�TA� DATE <br />Application Accepted By <br />Destruction Inspection By <br />COMMENTS <br />DEPARTMENT USE ONLY <br />Date <br />Date Employee ID# <br />rn <br />=1 <br />a <br />0 <br />0 <br />y <br />PE SC <br />Codes Info <br />Received Check#/ Amount Date <br />By ra--sh-Remitted <br />Permit/ Invoice # Well ID# <br />Service Request # <br />�37 3i d 1 <br />SlS7 rs�- 7 !4 0 <br />EHD 43-02-008 Well Destmction Permit Add 1W=.doc <br />3/3/2004 <br />