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ti681 '`N. WdH :E L106 'S1 'lnr ;Wli P;A ! ;D;d <br /> WELL DESTRUCTION vtwrl j <br /> ` PL-1—C WATER SYSTEM ❑Yes ❑N, 42 <br /> SAN JOAQUIN COUNTY ENvIROMNENTAL HEALTH DEPT 1868 East 1`111talton Avenue-STO-K7CN CA 95205-6232 -(2o9)4883420 <br /> ICON-REFUNDABLE PERMIT CALL(2,09)053-73-v7 i OR Sfis^CCTIOtIS EXPIRES 1 YEAR FROM DATE ISSUED <br /> Joa AooREss 22,100 S Jack Tone Rd GTY/zP - - 'y <br /> CROSS STREET Hwy, 4 APN 183-03-004 PARCEL SI2 LAND USE APPLICATION ai__ <br /> OWNER Craig & Gina Pad s a Trn Gt PHONE 2n9—AR.I 45,l]�n <br /> OWNER ADDRESS POpQx 17 lS C i? <br /> 2 3 6 I L <br /> CONTRACrOfl nrviance Drillers , Inc PHONE 209-887-3554 <br /> CONTRACTOR ADoitm P .O.Box 64 cITY/srATE2rP Linden, CA 95236 <br /> Cs WILL DRILIJirG L1cEAISE NuuaER 377923 ExPIRATION DATE 7/31717 <br /> PERFORATION CONTRACTOR PHONE <br /> I <br /> PERFORATION CONTRACTOR ADDRESS� CITY/STATEIZIP <br /> ❑ C-57 Well 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 BTlosives License Number Expiration Date j <br /> San Joaquin County Sheriff-Coroner Explosives Application and Permit License Number Expiration Date <br /> California Occupational Sarely Health-Blaster License Number Expiration Date <br /> REASON FOR DESTRUCTION a Dry ❑ Replacement Well ❑ Caved In ❑ Pit Well ❑ Inactive ❑ Test Hole <br /> Detected/Suspected Well Water C ontamin antls)­ t�*-,/g ; <br /> Adjacent propertywithcontamination(Address) /ltlet <br /> Known Soil/Water contaminants at adjacent property aha[ <br /> ExtsnNG WELT-CoustRycTioN DETAILS Open Bottom ❑ Gravel Pack ❑ Urcased ❑ Other _ <br /> Well Log copy attached Cl Yes No Grout Seat % Igo ❑ Yes_it below ground surface(bgs) Hole Dlameter inches <br /> Well Con ductorCasing❑ Yes No Depth ofCondu torCasing ft bgs Diameter ofCcnductorCasing inches ! <br /> Well Casing Dlameter1�inches Total Oeptlt�ft Depth to Water P Depth of Casing it bgs <br /> DESTRUMOY SPECTFICATION <br /> Sealing Material from ft bgs to 4r �R bgs Filler Material Cern,9,I from it Ings to R tgs <br /> Well easing to be perforated by one of the following methods: C191Ai from It bgs to ft bgs <br /> ❑ WIN Knife Number o.`cuts every ft and/or i <br /> ❑ Explosives❑ Detonating card ❑ with projectiles everyit ❑ without projectile <br /> ❑ Detonating card and boosters ❑ with projectiles every It ❑ without projectile <br /> ❑ Other i <br /> Sealing Material Neat Cement(94 lb bagl5-6 gal water) Sand Cement0 3 Sack rvr/7gal water Benlonlie Pellets <br /> Benton ite(20%solids) Manufacturer Spec 16 solids. _% Name Specs on File Specs Submitted <br /> Placement Method Pumded -ree Fat Other <br /> Seal Completion Complete with Mushroom Cap ftbgs Complete 10 Existing Surface Pad <br /> I HEREBY CERTIFY THAT I HAVE.PREPAR£D THIS APPLICATION AND THAT THE WORK WILL BE 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 UCENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> i;iir1 i.'JI'r -:(' .'t3!fai'C'1'•3G-:IC=;t<cCdUl't?=�SO!:!?ES?r=__CTiC1=iS <br /> CONTRACTORS SIGNATURE TITLE <br /> L.- rn <br /> EG O i1t 0 <br /> rri <br /> N <br /> %MOO <br /> EP <br /> R T M E N T USE ONL <br /> r <br /> Application Accepted By Date Area (W?jq <br /> Destruction Inspection BY Date Z`! Employee ID# <br /> COMMENTS p <br /> �W V <br /> PE Se Received Check#/0-- U7�' <br /> Amount Permit! <br /> Codes lnfd ash fitted Date ServieeRe uest# InvoErxtk Well ID# <br /> EHD43-05 WELL DESTRUCTION PERMIT <br /> 10"9107 <br /> Z'd tiL9£L8960Z oul sjellu4 aoutalAund dot C0 L L 9 L Inr <br />