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owl ti6E '1N Wd6E :E M6 cl Jnr MI J paAI ;3a� WELL DESTRUCTION rtKmi i Puauc WATER SvsTEN []Yes ❑N� SAN JOAQUIN CCUNTY ENVIROMNENTAL HEALTH DEPT 1868 East Hazelton Avenue-STOCKTON CA 95205-6232-(209)4683420 NON-REFUNDABLE PERMIT ❑f%L.(2109):i5 -?i£i For, EXPIRES 1 YEAR FROM DATE ISSUED Joa ADDRESS t22 S Jack Tone Rd CITYiaP CROSS STREET Hwy y 4 APN 183-03-004 PARCEL SIZZ31V LAND IISE APPLICATION 4 � OWNER CraigD& Gina Podes a Triist PHONE �n9-4RII—A_500r� G OWNER ADDRESS P 1,O O.X 17 0 cr lsTA7 jz,,, L i n d e n A 9 )C 3 C CONTRACTOR Purviance Drillers , Inc PHONE209-887-3554 CONTRACroR ADoREss P .0- B o x 6 4 CITY/STATE21P Linden, CA 95236 C-57 WELL DRILLIMC L10EN/5E NuR1aER 377923 ExPIRATION DATE 7/31/17 PERFORATION CONTRACTOR��/�C.- PHovE I PERFORATION CONTRACTOR ADORE55� CLTYISTATSILIP ❑ C-57 Well Drill ng License Number Expiration Date Bureau of Alcohol,Tobacco and Firearms-Users of High Explosives License Number Expiration Date CHP Hazardous Material Transportation for EEplosives License Number Expiration Date San Joaquin County Sheriff-Coroner Explosives Application and Permit License Number Expiration Date I California Occupational Safely Health-Blaster Licerse Number Expiration Date REASON FOR DESTRUCTION a Dry ❑ Replacement Well U Caved In ❑ Pit Well ❑ Inactive ❑ Test Hole Detected!Suspected We I I W ater C onlamin ant)s)�� Adjacent property vnth contaminati on(Address)_ Known Soil/Water contam iaan is at adjacent property ,.e/_ a Exis TING WELL CoNsTRucnoN DETAILS Open Bottom ❑ Gravel Pack ❑ Urcased ❑ Other _ Well Log copy ataclled ❑ Yes )f- No Grout Seal % No ❑ Yes It below ground surface(bgs) Hole Diameter inches �I Well Conductor Casing❑ Yes �I No Depth of Condu for Casing fl bgs Diameter of Conductor Casing Inches Well Casing Diameter _a_incineE Total Dept P, Depth to Water P Depth of Casing tt bgs DF.sTRC(TIOY SPECrF1cAT1nN Sealing Material from h bgs tO�r#q—ft bgs Filler Material Cf EYYIP11 t from R bgs to R bgs ' Well casing to be perforated by one of the fol lowi no methods- L � from it bgs to It bgs ❑ MITIS Knife NLmber of cuts every R and/or ❑ Explosives❑ Detonating cord ❑ with projectiles every ft ❑ without projectile ❑ Detonating card and boosters ❑ with projectiles every R ❑ without projectile ❑ other Sealing Mateflal Neat Cement(94 lb bag/5-6 gal water) Sand Cement 4. 3 sack rlir/7gal waist Bentonite Pellets Benton ite(20%solids) Manufacturer Spec It solids % Name Specs on File Spew Submitted Placement Method Pumped -ree Fall Olher Saal Completlon Complete with Mushroom Cap ft bgs Complete 10 Existing Surface Pad I HEREBY CERTIFY THAT I HAVE-PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN � JOAQUIN COUNTY ORDINANCES,STATE LAWS, AND RULES AND REGULATIONS- I ALSO CERTIFY THAT MY REQUIRED LICENSE IS CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION LAWS. 7 CONTRACTORS SIGNATURE I �� T(TLE DATE - " o - rn C-_ -.4 rn, S o �� w ` 23c�. Nei r o �E 1. 1 r WOW& E P R T M E N T USE O N L Application Accepted By Da;e Area Destruction Inspection By rS�`'' Date Zy Employee ID# COMMENTS p PE SC Received Check#( Amount Permitf Codes Info ash &r0ft od Dato Service Re uest# Invoice r- Well IEW EHD 43-05 WELL DESTRUCT.ON PERMIT 10,5107 Z'd bL9£L8860Z oul sjalp(]eoueimnd dOb:£0 L L 9 L Inf