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WELL DESTRUCTION PERMIT <br /> PUBLIC WATER SYSTEM ❑Ves ❑No <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 600 E MAIN STREET-STOCKTON CA 95202-(209)668-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS I CITY RIP , _ <br /> CROSS STREET C APN D, PARCEL SQED.,S5LAND USE APPLICATIONS <br /> JH 9,a Yic PHONE ." OOtL <br /> OWNER 4 ! <br /> CM,—T1ATT.ER4ZyI"P��7/g� <br /> nd 6:'i <br /> OWER ADazists ZPHONE <br /> CONTRA <br /> CONTRACTOR ADORE _CT'/STATEMPZ4,e n/ CA <br /> B—C-67 WELL DRILLING LICENSE NUMBER kZN 2/8 E"iI Txw DATE 5—� <br /> PERFORATION CONTRACTOR PHONE <br /> PERFORATKIN CONTRACTOR ADDRESS CrTY/STATEMP <br /> License Number Expiration Date <br /> ❑ C.57 Well Drilling Expiration Data <br /> ❑ Bureau of Aloohd.Tobacco and Firearms.Users Of High EXPIOSIVee License Number <br /> License Number Expiration Data <br /> ❑ CHPaum <br /> Hous Material Transportation for Explosives retlon Data '. <br /> ❑ San Joaquin County Shenff-Coroner Explmi"s Application and Permit License Number Data <br /> 3California OcCupallonal Safety Health-Blaster License Number Expiration <br /> Rg aDN POR DESTRUCTION ❑ Dry ❑ ROPlacement Well ❑ Caved In ❑ Pit Well native ❑ Test Hde <br /> Delected/Suspeoed Well Water Contaminant <br /> Adjacent Properly With contamirMOon(Address) <br /> Known SO,VWater conteminanm al adjacent property <br /> Gravel Pack ❑ Untased ❑ Omer 1.. <br /> E WELLCo ,,NUCTION DETAIn LS ❑ Open Bowm p� ids <br /> WNI Log WpY adached ❑ Yes p( No Grout Se d ❑ No ❑ Yes_ft baK w gr*und surface(bg5) Hoa Diametw <br /> �,/��� ft bgs Diameter of Conductor Caalrlg 9xhes <br /> Well Conductor W lrg❑ Yes �"' Depth N Contlu�cto�r Caaing t Depth of Casing ft bps <br /> Welt Caaing DlanwW manes Total Depth. Se. ft Depth W WaMr--.D —R DeP <br /> DESTRUCTION SPECIFICATION from It bgs l0 ft bgs <br /> Sealing Material horn IV ftbgsto L' ftbgs Filbr MNerial <br /> Y9i cad methods tram ft bgs to ft bps <br /> Well casing to be oa oreMtl by^^^^r"hIt" (t aM/or <br /> El Mills Knife Number of cuts every_ ft 13wiDloutprojectle <br /> ❑ Explosives❑ Detonating cod ❑ with projectfes every <br /> O Delonatin9 cord and boosters ❑ will projeCliles every <br /> R ❑ WhImt projectile <br /> ❑ Omersack mbJ!gal Water ❑ Bentonite Polio" �,.. <br /> Sealing Materlal .J Neat Camant(94lb beg/5.6 gal WBfef)❑ Sand Cement Sponte r File - Specs Submitted <br /> i/$entonite(20%solids) "' Manufacturer Spec%solids_% Name <br /> Placement Method it Pumped ❑ Free Fail OUB <br /> �s ft bgs E✓ComPlete to Existing Bullate Pad <br /> Seal Completion "Complete with Mushroom Cep <br /> RK <br /> LL BE <br /> NE <br /> I HEREBY <br /> COUNT' THAT <br /> ORDINANCES, STATE�LAWS,ED THIS <br /> RULES AND REGULATIONS.WIOALSO(CERTIFY OTHATNMYCREQUIRED ELCENSE IWITH S <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT 1 AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LA/YS. <br /> /NIM HOU( ADVANCE NOTICE REQUIRED FOR INSPECT ON�/ p <br /> 1 4 TITLE YDATE 7',O• 13 <br /> COWRACfMS SRINATURE <br /> ------------------------------ <br /> ( � �ej <br /> F-a u-, �g <br /> z LLI o <br /> r w> 2Q <br /> ob g a <br /> _� kc aLIJ <br /> e1 u Q <br /> aX <br /> DEPARTMENT USE ONLY <br /> I Date ( 1 Area 0 <br /> Appligton Accepted BY Da Employee IDN_ <br /> Oestructlon inspet6an B <br /> COMMENTS <br /> PE SC Racelwd Chealdll Amount Data Service Real Request N Invoice Wall IDN <br /> Colla Into B Cash Remitted <br />