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a <br />M8 "N AdOl:ti R[0Z '86'd9S awil paA[;D;� <br />WELL DESTRUCTION PERMIT <br />PUBLIC WATER Sn-rEM ❑ Yes o W <br />SAN JOAQUN COUNTY EMMONtAB1TAL HEALTH DEPT 1x68 East Hannon Avenue - STOCKTON CA 952CS-5252 - (208) 468-34120 <br />N1014 -REFUNDABLE PERMIT _ _ _ - - - EXPIRES 4 YEAR C r f <br />JoaAWREss 2JU8 Country biub 81 <br />ROM ATE SSUED <br />cramp Stockton CA 95207 <br />c.Qss STREET C a r o l t o n APNf4 T�PARCELS <br />' LD USE APPucATroN p <br />OWNER J P Wang <br />PHONE <br />OvmER Awksss <br />CITYISTATERIP f n C k n n t C A 5% n <br />CONTRACTOR Purviance rillers Inc. <br />_ <br />PHONE 209-887-3554 <br />CDnTRAcToRAObREss FOBo x 64 <br />Crryt5TArE0P Linden, <br />Cs7 WELL DRrLLIN6 LICENSE NUMBER 3 7 7 9 2 3 <br />Exp RAnON DATE <br />PERFORATION CONTRACTOR N/� <br />PHONE <br />PEAFORATI ON CONTRACTOR AbDRass /r/� <br />CITY(STATE(LIP <br />❑ G57 Well Or16ng <br />License Number Expiration Date <br />Bureau of Alcohol, Tobacco and Firearms- Users of High Explosives <br />License Number Expiration Date <br />CHP Hazardous Material Transportation ror Explosives <br />Uconse Number Expiration Date <br />San Joaquin County Sheriff -Coroner Explosives Application and Permit <br />License Number Expiration Date <br />Ca farnia Occupational Safety Heelth - Blaster <br />License Number Expiration Date <br />REASON FOR DESTRtX;nON ❑ Dry ❑ ReplacementWell ❑ Caved In n Pit Well k Inactive ❑ Test e <br />/ <br />Detected/ Suspected Wei IWaterContamin ant(s) Kr/t}- <br />df)A <br />Adjacent property with Contamination(Address) <br />Known Soil /Water contaminants at adjacent property <br />EwsnuO WELLCcNs-mucnoN DETAILS ❑ Open potlom ❑ Gravel Park ❑ UnceSed ❑ Other <br />Well Log copy attached ❑ Yes No Grout Seal ❑ No ❑ Yes <br />itbelow ground sturace (bgs) Hole Diameter inches <br />WeiiConductor casing Yes No Depth of ConduetorCasing <br />ttbgs DiameterefConduct orCasing inch es <br />Well Casing Diameter(inches Total Depth �it Depth to Water.��fl Depth of Casing It bgs <br />DESTRTICTTON SPEC1RCA7TON <br />Soaling Material hon —_O_lbgs to _AZ ftbgs FUIerMatedat_ <br />from ft bgs to It bgs <br />Well casing to be perforated by one at the following methods: <br />from ft bgs to it bgs <br />❑ Mills Knife Numberof arts every ft and / or <br />❑ Explosives ❑ Detonating cord ❑ with prnject1es every <br />ft ❑ without projectile <br />13Detonating card and boosters ❑ wtlh prajecOes every <br />ft ❑ without projectile <br />❑ Other <br />Seallag Material Neat Cement (941b bag/5-6 ger! water) Sand Came t saakinix 17 gal water 8entgnite Pellets <br />Bentonite(20%solids) Manufacturer Spec A Name <br />Specs pe-Submitied <br />Placement Method Pumped Free Fall Other <br />Seal Completion Complete with Mushroom A bgs <br />Complete to Existing Surface Pad <br />ncnr- I 0""T ZI t HAW: IIKLPARED 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 REOLARED LICENSE IS <br />CURRENT AND ACTIVE WFTH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE 1111TH ALL <br />WORKERS COMPENSATION LAWS_ <br />CONTRACTORS Sir. R> Tn,' Secretary - &D 28/18 8/18 <br />�YtijFNT <br />Qelve6 <br />4 2018 <br />rYCN7,I/N7y <br />'gRTMENl <br />Application Accepted By <br />Deslnmtlon Inspection By <br />COMMENTS <br />F�PARTMENT <br />USE ONLY, <br />Dale o V}^ <br />Date ° <br />Ane. l� 4 <br />Employee IDS d <br />PE SC I Received ChedkS! <br />Codes Info By„ ,Cash <br />Amotrnt Date <br />Remitted <br />Permit/ <br />Service Request f1 <br />invoice l WeI11DdF <br />EH D 43 -OR <br />tastaT <br />WELL DESTRUCTION PERMIT <br />Z -d VLSEL2960Z out sJalp(] eoueiAind dZti:�O 9L 8Z deS <br />