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•� _ 3\ _ 2� c-�M �5��t�11oN ►t 1°l�l I GA'TI ��. <br /> PUBLIC WATER SYSTEM ❑Yes ad No <br /> SAN JOAQu1N COUNTY ENvIRONMENTAL HEALTH DEPARTMENT 1868 East Hazelton Avenue-STOCKTON CA 95205 - (209)468-3420 <br /> NON-REFUNDAB'IX PERMIT CALL 209 953-7697 FOR INSPECTIONS l EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS 1 / CITYIZIP 11 !it a Eu <br /> CROSS STREET IOU I S0 MV-el- APN I U PARCEL SIZE LAND USE APPLICATION# <br /> OWNER R ,S1-�l l/t W ol Lm C/V�D• PHONE ZOaI X 22 • (;I Z7- <br /> OWNER ADDRESS DOX CITY/STATE/Z <br /> IP <br /> DM6 TI) �}B701 <br /> CONTRACTOR M�MPHONE LlM 2Z- 1 q z(.?. [� <br /> CONTRACTOR ADDRESS I N CITY/STATEmP I2r L CJ "^ <br /> C-57 WELL DRILLING UCENsE NUMBER EXPIRATION DATE ,. <br /> PERFORATION CONTRACTOR PHONE <br /> PERFORATION CONTRACTOR ADDRESS Cf TY/STATFJLP <br /> C-57 Wei Drilling License Number U It ?/ Expiration Date Ai <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 11tt Expiration Date <br /> REASON FOR DESTRUCTION ❑ Dry ❑ Replacement Well ❑ Caved In ❑ Pit Well tiL Inactive ❑ Test Hole <br /> DetectedlSuspected Well Water Contaminant's) 7� <br /> Adjacent propertywAh contamination(Address)____ _ <br /> Known Soil/Water contaminants atadjacentproperty__..___. <br /> ExisTING WELL CONSTRUCTION DETAILS ❑ Open Bottom Gravel Pack ❑ Uncased ❑ Other <br /> Well Log copy attached ❑ Yes ❑ No Grout Seal ❑ No ❑ Yes ft below ground surface(figs) Holo Diameter Inches <br /> Wen Conductor Casing❑ Yes ❑ No Depth of Conductor Casing ft Diameter of Conductor Casing fiches <br /> Well Casing Ofarneterinches Total Depth2,�_ft Depth to Water.--_ft Depth of Casing ft bgs <br /> DESTRUCTION SPECIFICATION rr � <br /> Sealing Material from 0 ft bas to7-9v ft bgs Filter Material __ from ft bgs to A <br /> Wel)caping to be�r �d Dy one a it w n from ft bgs to ✓� <br /> Milia Knife _� Number of cuts every _ Il and/kx..- -- �IAE7B V <br /> Explosives ❑ Detonating cord ❑ with projectiles every_ ft ❑ Without prolectle /A p, <br /> E3 Detonating cord and boosters ❑ with projectiles every_ ft 13 without projectile r V '/g <br /> ❑ other--- SA/V'/0 ??0' 4 <br /> Pal SLal Ing Material Neat Cement(94 tb bag/5-6 gat waler� Sand Cement sack mtx/7 gal water /( /N C <br /> Bentonite(20%solids) Manufacturer Spec%sol,ds % Name Specs on File S /Vj oU TY <br /> Placement Method Pumped Free Fag Other T <br /> Seal Completion Complete With Mushroom Cap ft bgs Complete to Existing Surface Pad <br /> MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS, CALL(209)953-7697 FOR INSPECTIONS <br /> DEPARTMENT USE ON�7-3 <br /> �fApple ation Accepted By Date 2 7 Area <br /> Destruction Inspection By Date Employee ID# <br /> COMMENTS <br /> PE SC Received CheckIN Mount Parm#t1 <br /> Codes Info B Cash Remitted Date Service Request I Invoice I Well IDS <br /> Y17V 1415 -�� .325 '0q?.'312'1 WPram� 23m - - <br /> (�W- l ?509371 a <br />