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May 13 10 10:10a Ken Gross Wells & Pumps 209-745-8584 p.3 j <br /> WELL DESTRUCTION PERMIT <br /> PUSUC WATER SYSTEM 0 Yes 0 No <br /> $A\JOAQLUN COLxry ENW RONNCNTAL HEAL71t DEPARTIMEtYr <br /> 384 E WEBER AVE 3`a FL-STOCKTON CA 95262•(269}468.3120 <br /> NON-REFUNDABLE PERMIT CALL(209)953-7697 FOR INSPECTIONNS EXPIRES i YEAR FROM DATE ISSUED <br /> Cm2tP <br /> JOB ADORES - Y <br /> CwDssSTgEt;7/�1 ' PARCEL So v USE APPLICATION <br /> OWNER'f1lT !L�� F t/>QCi1�T1�L'� PFItWE t <br /> C MYIFTATEM <br /> OWNER ADDRESS <br /> CON-ritAGr'ost PHONE �/t� <br /> CON <br /> TRAG RADDRFSS —4:5 - L CrTYISTATF/ZIP <br /> (��/ DATE„ ✓ly l ��� <br /> C-S7 WELL DRILLING LtcENSE NtEtsBER EXPIRATION <br /> PERCO7tAITON COWRACrOR PHOAE <br /> PEitFORATION CONTRACTOR AODRE S C Crv/SrAfEJZ1P <br /> License Number Expiration Daze <br /> ❑ C-57 Wcli Drilling raripu Dare <br /> [3 Bureau of Alcohol,Tobacco and Firearms-Users of High Explosives L cenu Nu r,ber PA pi <br /> rtation for Ex losivts License Number Expiration Date <br /> ❑ CHP Hazardous blattsiai 7ranspo D $7cpiratinn Date <br /> ❑ Sas jwquin Covoty Sht:iff-C__Sxplosives Application and Permit License NumW Ea ;ration Gate <br /> ❑ CalifomisoccupariorwSarmHcalth-Blaster License Number P <br /> it_.t�'1ra t r)RD SSB TRt_K-r'�or+ Dry 0 Replaeemern WeR [3 Caved In ❑ Pit Well1n.ctie [] <br /> Ttac Holt <br /> Detected!Susptcted WNI Water Contaminant(a) <br /> AdIdodat property with eontatdoatloo(Address <br /> Keown Sal!Warer contatnittaats at adjUML propary <br /> LoWELL CONSraUCrxlN nEruLs A OPer.Bottom ❑ Gravel Pack ❑ tlneased L] Otter <br /> wen Log copy attached ❑ Yes ❑ No Grour Stal ❑ No ❑ Yes ft bebw ground avrfaee(bgs) Hok Dlntoskr inches _ [ h` <br /> Well Conductor Casing ❑ Yes V No Depth or Coadactor Ca:)ag ftbgs Diameter of Conductor Casj inobm v�r <br /> Well Casing Madder I L inches Total Depth- R Depth to Water ft Depth of Casing ft bp N <br /> „rr,9nr-rtoNgpeaFltATwN ��,� <br /> Sealin Maieridl from nbgsto ftbgs izMerMaterlald,-{I7J'� —from ftbgsto Rbgs <br /> >: A b <br /> wdl eaaing to he gr(�CY.�M'g"""t M e rnibwiae rnetlloda: from ft bp to St <br /> ❑ Mins Knife ywr>tiu of cuss every ft and J or <br /> ❑ withprojddhiesevery ft 13WitAourptojtttik „ l <br /> ❑ ExpbtWas ❑ Detonating cord <br /> ❑ Cetonuing cord and bodatera C3with prdl <br /> ojecrs everyfl O widioutproj=Wc <br /> ❑ other <br /> �� ��'�"'ok oris!7 gal water ❑ $eMonlM e <br /> Sealing Material ❑ Neat Corrent!9a lb hog f 3-d gut wr+rc+j Scrod Cetnent�Q ore-{��"' <br /> Manufacturer Spec 95 solids Name ❑ Spas on File ❑ Sous SuMnitted <br /> • ❑ Bentonite{20%solids) ❑ •la x -- <br /> Placement Mrtbod❑ Pumped ❑ Free foil {� other 3VJ YY't Surface Pad O <br /> Snl Compledon CoarpKte with Mushroom Cap ft bo 13 �mplere to Extstitly <br /> I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> JOAQUIN COUNTY ORDMNANCES,STATE LAWS,AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE 1S <br /> THAT 1 AN IN COMPLIANCE WITH ALL <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND P'E�r <br /> WORKERS COMPENSATION LAWS. <br /> N NiMIJ 24,HOER ADVANCE NOTICE REQUiRED OR INSPECTIONS <br /> TITLE DATE —• V �� r A� <br /> CONTRACTORS S4GNATVRE <br /> 0 <br /> '& PpN�`n vE� <br /> �►� ,� ~� 3 241fl �° i <br /> sxsN R�M� <br /> rN. p~PAR <br /> DEPARTMENT <br /> PARTMENT USE ONLY •///yp.� <br /> .4ppli"bon Accepted By -- Date <br /> Area <br /> Destruction inspection B Dau Employee IDI - <br /> COMMENTS L a, <br /> i <br /> PE SC RecelvM kyJ Ardouat Date PC it/ lnwltxR Wd1 IDH <br /> �•y'-.+.. Infer 8v h Remitted e+ Service Rt nest Uri <br /> • 41 .ZOO" J p 7J <br /> Was tbw,cGor r— <br /> ERD0I-0:-Wa <br /> I/27/Ma1 <br />