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WELL DESTRUCTION PERMIT <br /> Pt�WTER. SYSTEM ❑Ves`�.�No <br /> SAN JOAQUIN COUNTY ENORONMENTAL HEALTH DEPARTMENT ago E MAIN STREET-STDCKTON CA 95202-(209)4n-U20 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES'I /YEAR FROM DATE ISSUED <br /> JOGADDRE66 COZGP dL 1J n <br /> CRDs STREET APN PARCEL Sill_"No USE APPDGTONM p <br /> P <br /> OWNER ywl PHONE <br /> OWNER ADDRESS CRYSTFTEZP { <br /> CONTRACTOR PHONE . 1?� � <br /> CONTRACTOR ADDRESS N' 91 CTTY/SfATE17IP • G <br /> C457 WELLDRIUUNG LICENCE NUMBER 7 V E-IRATION DATE�/ G�� <br /> PERFORATION CONTRACTOR -- <br /> PHDNE <br /> PERFORATION CONTRACTOR-Z.RESS � CITYISTATEQIP <br /> 457 Well Drilling License Number I d, Expiration Date <br /> Bureau of Alcchol,Tobacco and Firearms;-Users of High Explosives License Number Expiration Dale <br /> CHP HaxardDus Material Transportation for Explosives License Number Expiration Data <br /> San Joaquin County Sheriff-Comner 6ylosives Application and Pemut License Number Expiration Date <br /> California ODDlpational Safety Health-Blaster License Number Expiration Date <br /> FD�CPON ❑ Dry ❑ Replacement Well ❑ Caved In O PA Well ❑ Inactive est Hole <br /> Detected/Suspected Well Water Contaminants) <br /> Adjacent property With contamination(Ad <br /> Known Boil/Water contaminants at adjacent properly_ _. . <br /> ExISTING WEU CONSTRUCTION DETA l5 ❑ Open Bottom ❑ Gravel Park ❑ Unrased ❑ Other <br /> WNI L09 COPY etreole0 ❑ Yes X[N0 Grout Seal ❑ No ❑ Yes fl below ground surlsoe(bgs) Hole Diameter imhes <br /> Well Conductor Casing❑ Yes `SC No Depth of Conductor Casing <br /> it Diameterof Conductor Gsin._. nes <br /> Well Casing Diameter inches Total Depth fl Depth to Water it Depth ni Casing fl bgs <br /> D ON CPECIFICATON <br /> Sealing Material from flbgsto Ga!l flbgs Filler Material from 11bgs to flbgs <br /> Well casing to be cerlorafetl by one of the followina methods' >A e4 from R bgs m fl bgs <br /> ❑ Mills Knife Number of Ms every t and/or <br /> ❑ Explosives❑ Detonating cord ❑ with projectiles every it ❑ vAthoul pmjecdle <br /> ❑ Detonating cord and boosters ❑ with pmjecbl s eve? it ❑ witlwA projectileDtMr <br /> JNP NZ &Z <br /> Sealing Material eat ment ag/5-6 gal wa Sand Cement Sack mix 17 gal water Benton'de Pellets <br /> Bentonite(20%so user pec%solids_% Name Specs on File Spays Submitted <br /> Placement Method Pum Free Fell Other <br /> Seal Completion Cc a Mushroom Cap_ -3 it bgs Complete to Existing Surface Pad <br /> • I HEREBY CERTIFY THAT I HAVE PREPARED 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 LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> MINIMUM 24 HOUR ADVANCENOTICEREQUIRED FOR INSPECTIONS <br /> CoNmADTOR3$IGNANRE TITLE DATE <br /> C7% _ -___ <br /> ✓/,ter,,,- �,,- <br /> « �cr2�i ED <br /> z FEB 1 7 2 9 <br /> l ENVIRONMENT. H ALTH <br /> PERMIT/SEBVI JES <br /> DEPARTMENT USE ONLY <br /> Application Accepted By Date Area <br /> Destruction Inspection By Date Employee IDs <br /> COMMENTS <br /> PE SC Received Checlo9 Amount Dare PemTW Invoice Well IDR <br /> Codes Info B Cash Remittetl Service Rol seal# <br /> WELL DECTRUCTION PERMIT <br /> EHD 4306 <br /> t0I5mT <br />