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WELL DESTRUCTION PERMIT <br /> PUBLIC WATER SY57M ❑Yea ❑No <br /> SAN JOAom CouxTY EOWRowwNTAL HEALTH DEPAwntaENT ISM East Hasalton Avenue-STOCKTON CA 95205-(209)4684420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR bisPEcT10Ns EXPIRES 1 YEAR FROM DATE ISSUED <br /> I w <br /> Joe ADDRESS CrrYfz p <br /> CROSS STREET APN DFOPARCEL SIZE(-RLANO <br /> USE APPLICATIONi <br /> Ownat <br /> j OWNM ADDRESS V CRYISTATE" v <br /> CON RACTOR r !) C - I PHONE 512 <br /> CONTRACTOR AODIItQa III RIM N. CRTf3TATERN' <br /> C-57 WELL DRa ma LWAMU NU11sEtt /w4 E).11.11 N DATE <br /> PERFORATION CONTRACTOR PHONE <br /> PERFORATm CONTRACTOR ADDREsa CmISTATrMP <br /> ❑ C-57 Wei Drilling License Number Egwation Date <br /> ❑ Bureau of Alcohoi,Tobacco and Firearms-Users of High Explosives License Number E)iration Date <br /> ❑ CHID Hazardous Material Transportation for Explosives License Number Expiration Date <br /> ❑ San Joaquin County SherlR-Coroner Explosives AppHcativn and Perri* Lio nse Number Exxplraft Date <br /> ❑ California Occupational Safety Health-Blester Lmmrre Number Expiration Data. <br /> REASON FOR DUTRUC" Dry ❑ Replacement Well ❑ Caved In ❑ Pit Well ❑ Inectm ❑ Test Hole <br /> Deted"Suapected Wed W arkt(s) <br /> i Adjacent Property with eoeftan instlon(Address) <br /> Known SoillWater contaminants at adjacent property -_- <br /> ExwTl o WELL CowsrRUCTrON DETALS ❑ Open Bottom Gravel Peck ❑ Un ased ❑ Other <br /> Was Lop copy attached ❑ Yes ❑ No Grout 3sal ❑ No O Yes ft below grand surface(bgs) Hole Dlarkketsr owes <br /> War Conductor Casing Yes ❑ No Depth of Caslrg ft Diereeter of Conductor CasWgp es <br /> Wall Casing Dlam+ater Inctm Total Depth R Depth to Weller ft Depth of C.04 r xbgs <br /> DESTRUCT*N SPECIFICATION UCT <br /> Soling Material from_._�ft bgs to ft bgs FlUer Matsrlal from ft bps lo zU hl <br /> Well casing to be D*r_fQneted by om Of theI frOrll It bgs to san�onok <br /> ❑ Millie Knife _ Number of cub every ft andfor HEALTH p"q,tTM1 ENTM <br /> ❑ EvlosMes❑ Detonating cord ❑ with projecres every ft ❑ without projectile <br /> D Detonating cord and boosters ❑ with projectiles every ft ❑ wlthart projectile <br /> gp❑ Othw <br /> Pdists Mg MabwW j Meg Cement(941b bag5r8 gd webw) Sand Cowwd sack moll gal water )�Bw toniM <br /> Bentonks(20%saws) n A aduer Spec%soids % Name Specs on File H Specs SubrrNned <br /> Ptacamwd Medwd ❑ Pumped ❑ Free Far ❑ Other <br /> Seal CompWm L Complete with Mudwoom Cap r It bgs r- Complete to Endstlnp Surface Pad <br /> MINIMUM 24 HOUR ADVANCE NOTICE REGURED FOR INSPECTIONS,CALL(209)953-7697 FOR INSPECTIONS <br /> DEPARTMENT USE ON V C <br /> Application Accepted By I' /- Date o Area 7 <br /> Destruction Inspection By Date Empbyee IDik_ Aq <br /> COMMENTS <br /> PE sC Reoslved CheeldV ANwrNtt Doss Perwdv Mrvolca s WON nil <br /> Codes kMo RerrrNled • <br /> p o IS <br /> EM 43M ` Z ( Z 2— ` / WH1 DC3TRUCTK)N PERMR <br /> 111MI <br />