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WELL DESTRUCTION PERMIT <br /> PUBLIC WATER SYSTEM[]Yes L7 rro <br /> SAN JOAGUIN COUNTY ENviRoNMENTALHEALnI DEPT 1868 East HaXolton Avenue-STOCKTON CA 95205.6232-(209)466.3420 <br /> NON-REFUNDABLE PERMIT GAIL 203 353-71397 f-ort INrrt'rr.imim EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB AuDRES$ I CITYIZIP <br /> CROSS STREET j"ST i APN 1 �•L_-_PARCEL SI a SE APPLICATION <br /> qd <br /> 01 ima 2P PIwNE_cQ5/)41(6- -T}I rn' <br /> OWNER AOORFSS 4 O CITYISTATFILM„� ` rQ r <br /> CONTRACTOR /► � PHONE `j i Q, <br /> CONTRACToRAO � <br /> DR63S� ` MF O.V OM Ale CITVISTATsrZ- ��6U`•1 V <br /> C-57 WELL DRILLWO '.gLICENSE NUMBER 31,0 <br /> 1�i EXPIRATION OATC I D d <br /> PERFORATION CONTRACTOR W-el'omCn(AY�t•�q„rt.�t_i . eL.• PHONE .� <br /> PERFORATION CONTRACTOR AUOREnSs �JvZI_�I__I/UDprlmC,TY/STATfJZP _(��iaf3 <br /> d C-S7 WeR Drilling T►�L I-%ID License Number aF��palrat ag' <br /> Bureau ofAlcolol.Tobaccoandfirearms-UsersofIlighExplosives License Number i•33 EzpiralWale <br /> CHP Hazardous Material Transportation for Explosives License Number Expiration Dale <br /> San Joaquin Counly Sheriff-Coroner Explosives Application and Paring License Number Expiration Dale <br /> California Occupational Safely Health-Blaster License Number a Exp-valion Date <br /> REA"FOR DESTRUCTION ❑ Dry ❑ Replacement Wall ❑ Caved In ❑ Pit Well germelive ❑ Test Hole <br /> Delecled)Suspected Well Water Contalninant(s)_'rp �fl7r..t <br /> Adjacent property wRh contamination(Ad(tress) <br /> Known Sail/Water contaminants al adaceN property I-j 11 <br /> EXISTING WEUCONSTRUCT1W DETAILS 0"Open Bottom ❑ Gravel Pack ❑ Uncased ❑ Other <br /> Wall tag copy attached ❑ Yes WNo Grout Seat @o'No ❑ Yes_n below ground surlace(bgs) Hole Diameter Inches <br /> Well Conductor Casing 13 Yes Ir No Depth of Conductor,Casing It bgs` Diameter of Conductor Casing inches <br /> Well Casing Dlsmeter 11 3!_�inchas Total Depth_ t-1 R Depth to LVator,1 .Id R Depth of Casing___R bgs <br /> UiST1l11fT/AV AfF.t'IPIGlIOV /t �y� �j►�,Q� <br /> Seating MaMNat from 3i"1 Wbas to U n bgs Filler Material (/7/`�_from _n bgs to_ R bgS <br /> Well casing to ba rat by o e of a foliowt Rretho • from _R bgs to 2 60 R bgs <br /> ❑ Mills Knife Number of cuts every_ nand la <br /> Ee'EXplosivas❑ Detonating cord ❑ with pmjedles every R ❑ without projectile <br /> 9"Delonalirg cad aid boosters Er with projectiles every=R O willwul projectile <br /> ❑ Other <br /> Sealing Material Neat Cement(94 Jb bag/5-6 gal water) Sand Cement IA.3_sack mix 17 gal water Bentonite Pellets <br /> Sentonito WA sol-Ids) tadurer Spec%solids_% Hama Spats on FgP Specs Su m4ledl. <br /> Placement Method umped Free Fall Other .3 n 7h <br /> Seal ComplaUon Complel Mushroom Cap R bgs 1'9 - <br /> 1 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 TAY REQUIRED LICENSE IS <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT t AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> MINIM UM?. f UR ADV NCNOT �REQUIREFJ FOR INSPECTIONS r1_ <br /> CONTRACTORS SIGNATURE TITLE' 14 4 <br /> SL <br /> 15 A* <br /> pAYM�NE <br /> RECEW <br /> SA <br /> 34Rp P# TyEIIT <br /> D E 7 J9O N��/�I'r <br /> hXJAppricalion Accepted 8 , ot3t o -I Area <br /> Deslniction Inspection By LE. CA&---J Dale � �d/� Employee 108 <br /> COMMENTS � �' G J <br /> PReceived Checkyl Amount Date PermlV invoiced Well 11119 <br /> !dCC <br /> o B Cash Rornfited Ser-ViccRe Gest!! <br /> EHD 43.09 WELL DESTRUCTION PERMIT <br /> Ia&07 <br />