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WELL DESTRUCTION PERMIT <br /> PUBLIC WATER SYSTEM ❑Yes ❑No <br /> SAN JoA m CouNTY EwRoNMEXTAL HEALTH DEPARTMENT I W8 East Hazelton Avenue-STocKToN CA 95205 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> Joe ADDRESS CrrY/LP A 61 M <br /> CROSS STREET APN OW PTO PARCEL SC BLAND Use APPLecAmm aR <br /> OWNER G PHONE <br /> OWNER ADDRESS fj` CITY/STATE" <br /> CONTRACTOR I kl� 1 PHONE ' <br /> CONTRACTOR ADDRESS M ftNIK CrrY/STATEfZP '�V <br /> C,57 WELL DRLLi*G LICENSE N,mmm y ExPIRATION DATE <br /> PERFORATXM CONTRACTOR PHONE <br /> PERfoaATm CoNTRAcTOR ADDRESS Cm/STATEIZV <br /> t7 C-57 We4i Drilling License Number Expiration Date <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 Expi /^to <br /> ❑ Cafifomia Occupational Safety Health-Blaster License Number Expi l7aleY <br /> REASON FOR PuTgummDry [IReplacement Well Caved In ❑ Pit Well ❑ Inactive <br /> Detected/Suspected Well W Contaminant(s <br /> Adjacent Property With contaminatlon(Address) ?i '/Z <br /> Known SoiVWater contaminants at adjacent property � <br /> El4STlt16 WELL COMOTRUC"M DETAti-S ❑ Open Bottom Gravel Pads ❑ Uncased 4 LT Nh1E NTY <br /> Well Log copy attadied 13 Yes ❑ No GroW Seal ❑ No Yes __._ft below ground surface(bgs) I Dlarrrete► TM s <br /> Well Conductor Casing❑ Yes ❑ No Depth of Conductor Casing ft bgs Diameter of Conductor Casing inches <br /> Well Casing l3im _ inches Total Depth- o___ft Depth to Water It Depth of Casing it bgs <br /> DE8TRUI;IM SPECFXATION <br /> Sealing Material from R bgs to It bgs Flller Material from ft bgs to ft bgs <br /> Well casing to be Sdr by ang ofthe following methods: from It bgs to It bgs <br /> Milk Knife Number of curls every ft and/or <br /> Explosives ❑ Detonating cord ❑ with projectiles every ft ❑ without projectile <br /> O Detonating cord and boosters ❑ with projectiles everyft ❑ WMXXA projectile <br /> ❑ Other <br /> Pei speding Material Neat Cement(94 1b bag/5-6 gal water)a Sand Cement sack mbc/7 gal water !1 Bentonite <br /> Bentonits(20'✓. Ids) a Manufacturer Spec%solids % Name --1 Specs on File i! Specs Submitted <br /> PI Ent Met Pumped Free Fall Other <br /> Seal Completion plete with Mushroom Cap It bgs ❑ Complete to Existing Surface Pad <br /> MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS,CALL(209)953-7697 FOR INSPECTIONS <br /> DEPARTMENT USE ONLY/ S �� <br /> Appbication Accepted By L 1- Date 8 31//a"o Area <br /> Destruction Inspection By n[ 6,1G?ilua t jZ Dat. / Employee iEw A6 _ <br /> COMMENTS Or►airto l for well ri6t IoC4teC4- <br /> Cot✓t�/GG�or Geirtl /e S. <br /> PE SC RAC~ Checid/ Amount Pemm Invoice S Well IDA <br /> Codes Into BY Cash Rwnittsd Service i <br /> , 31q L( S - 3oZS <br /> EHD,3- g Jf,��L `/f/ WELL DESTRUCTION PERMIT <br /> 11 r23121 <br />