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2002/002 <br />MININIUM240 CE NOTICE REQUIRED FOR INSPECTIONS <br />TITL dAticr CONTRACTORS SIGNATURE: <br />Application Accepted B <br />Destruction Inspection <br />. COMMENTS 14P <br />II <br />' • AI <br />AgArnif <br />/ <br />nErARTmENT USE ON! <br />Data <br />Date <br />4/11 /2 008 FRI 11:00 FAX 2094663433 SJC EHD <br />WELL DESTRUCTION PERMIT <br />PUBLIC WATERSYSTEM Dyer 0 No 6‘ R 8 2008 <br />SAN JOAQUIN COUNTY ENVIRONSIENTAL II EALT/I DEPARTMENT <br /> 600 EAST MAIN STREET- STOC/CTON CA 95202 - (209) 4611-3120 <br />AfJ,(2O9r 953-7(r97 F 1 INSPECTIONS ...... .... <br />JOIS ADDRESS 372.['Mut Cirynn. I nu-, y • PE ' OWNER 5Nett cat Proliticks tAS <br />OWNER ADDRESS Sat at li#41,1V3t, el VP It> Cm/STATE/ZIP Cadieu <br />1 <br />x A 9044) <br />CONTRACTOR rno N E (705) 1Th15 "41210 <br />CONTRACTORADDRESS Hill RiOef$140, Dr...... I+ 230 cirwsurvzip Sdiali 1 CA 4,61176 Awe <br />0 C-S7 WELL DRILLING LICENSE NUMBER C-5 7 V.K-i 1(0. -- EXPIRATION DATE i (X( ar/0 <br />rERFOILATION CONTRACTOR GIVIFill:) P11110.34 PRONE c-er z(3-__acei <br />PERFORATION CONTRACTOR ADDRESS Lao 'kale 6,20( 0ms...rm.. 4' t9 el Yir..? <br />BeC.52 Well Drilling Licerme Number 181,—?c4, Expiration Date I iIi kii u <br />0 Bureau Alcohol. Tobacco Firearms- Users of High P.splosives LiC.C.A.SC Number Expiration Dale of and <br />0 Clip Material Transportation for Explosives License Number Expiration Date Hazardous <br />0 San 1011Cplin County Sheriff Explosives Application and Permit License Number Expiration Date -Coroner <br />0 California Occupational Safety Health - Blaster License Number Expiration Dare <br />REASON FORDESTRUCTION 0 Dry 0 Replacement Well 0 Caved In 0 Pit Well llielnauive 0 Test Hole <br />Detected / Suspected Well Water Contantinant(s): <br />Adjacent with contamination (Addiess): property <br />Known Soil /Water contaminant' at adjaceitt property: <br />WELL CONSTRUCTION DETAILS 0 Open Bottom 0 Gravel Pack 0 Unused 0 Other EXISTING <br />Well Log attached lYes 0 No Grew Seal ta No ii You ft below ground surface (bgs) Mile Diameter till inches copy <br />Well Conductor Casing 0 Y,,s 0 No Depth of CooductoriCasing fl bgs Diameter of Conductor Casing inches <br />Well Casing Diameter inches Total Depth 22 11 Depth to Water ..___ A Depth of Casing 11 ft bgs _q <br />DESTRUCTION SPECIFICATION <br />Sealing Material from 122.. Il bgs to 0 .3 ft bgs Filler Material bkVA 711 from n bgs to Cenb es <br />Well easing to be perforated by one a the following_ methods from R bye to ft bgs <br />0 Mills Knife Number of curt every ft and / or <br />0 Explosives C Detonating cord: 0 with projectiles every II 0 without projectile <br />0 DelOnating cord and boosters: 0 with projectiles every ft 0 without projectile <br />0 Other <br />Sealing Material ---V—N-Tart Cement (9./ 16 hog 15-6 gal older) 0 Sand Corn eftt . sock mIx 17 gal water 0 Bentonite Pellets <br />0 Bentonite (2O% solids) 0 Manufacturer Spec % solids % Name 0 Specs on File 0 Specs Submitted <br />Method life Pumped El Free Fall 0 Other Placement <br />Seal Completion: Vf compw. with Mushroom Cop 3 ft bgs I Complete to Existing Surface Pad <br />I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL DE 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 I.ICENSE BOARD AND TIIAT I AM IN COMPLIANCE WITH ALL <br />WORKERS COMPENSATION LAWS. <br />PE <br />Codes <br />SC <br />Ian <br />Received <br />, By <br />CheckN/ <br />Cant, <br />Amount <br />neenitted Dote <br />Permit/ Invoice N <br />Service Request N <br />Well IDN <br />SC•M <br />A <br />0° --. ilk- /4409 6,o.vi , . _ ..,,,; ;ALo,...._ <br />---- ..r. ......i 4.... <br />F.II941•02.0DI writ <br />nil 1/10D7 <br />a2b .1.4.1kTemirAddar.A.Indoc <br /> <br />7 <br />EXPIRES 1 YEAR FROM DATE I NMENT FIFALTil