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WELL DESTRUCTION PERMIT <br /> PUBl1CWATERSYSTEM ❑Yes XNo <br /> SAN JOAQM COUN]Y ENWa EWAL HEALTH DEPT 18"Best HamROn Avenue-STOCKTON CA 962058232-(209("ll <br /> NON-REFUNDASLE PERMIT CAL.12DY.1 96]7bS7 Ff1 t'4`:r• EXPIRES 1 YEAR FROM DATE ISSUED <br /> Joe AOOREas Ilwy L4 <br /> �/� CmZP FCY`J�Mt f\0�-1-p r-1 �s z!)o <br /> TR <br /> CRMSSEET APN187-11D-14I ARCELSRS��s��LANDIIea AYryIGTNINN _ y <br /> DWNER r PNow L"1-1 <br /> OVMER AOOeeen Cm5rATE)LP S�-eeK+nn.cla g5z16 <br /> Co. <br /> Co„]RaCTORADDREaa CMJSTATVhP el 1CY]tJ'Ta. �e� 4 56 <br /> C47WELLOMLLJN Lcs.eac Nuttal .180013 Em nON Dan <br /> PFgfaRATMN coNmAcroR S- C ` PNO„E rv45-11 <br /> PEI�`60// -M CONTRA11W1 AIDREa9 3 a\a [�V-S._CnyiSTATEFd��Cc.FO/ C R9rs"✓�356 <br /> C 97 Well Drilling L;C SeNunnbefZqo8iss E�xpftbw Date <br /> re + <br /> Buae Of A L,Dh1 ',To>acc0 and Firearms-Users of Hlpe ExpiOvvea LirnaW Number�Cl�heti0n Dab S _y <br /> CMP H.Moua Malenel Tranbponalbn for Evpba l; U.Number EapIrMlOn Data <br /> San Joaaun County SWII-Crooner EVIcerves Application and Parma License Number <br /> Caslornla Omrpational Safety Health-SlastmEapi,,,en Data <br /> Lkellse Number Eapadbn Dab <br /> REAON FOR DEe mucnO„ ❑ pry ❑ Rapi.aang Well ❑ Caved In <br /> ❑ Pit Well IneLtiva ❑ Test Hole <br /> Deledad/5uspedetl Well Water COntamlMnl(a� <br /> Adjacent Properly with Contamination(Adarefa) <br /> Known Soil]Water contaminants at adacenl Property <br /> EnanNc WEu CONSTRLYnONDET M a Ocen Samoan D OnLeIPIK* ❑ LyKasad ❑ Omd <br /> WNI Log aPY aitaCietl ❑ vu ❑ NO Grout Seal ❑ He O Yaa_p beW G p nc sura®(b¢) Nota dameHr incees <br /> Wau Conductor Caving❑ Yes ❑ fab Dean or CoMiga CaMp R bq DIemHR o1 DaMYGtp GMnp InW. <br /> wa„C",Dlamner Yf IMos Te""DePni z-MI—R DCPI to Wgar 11-1 R Deal,of Caabp now] <br /> D� G <br /> SeaOnp Metanal 9cm bwn CIL� fl Ops Full e)MabHal_} _it"_,�p_ROpSto�_R bps <br /> Well casing to ba a byane a fol o in mat s: +( tmm 'O R bps m�'&tillage <br /> �},'/�Mille Knife NurMrrol mis every Rand/Or, <br /> 9 EEPbslres❑ DebnaLnp wM ❑ wiN pro{adlks awry R D will pmfocue <br /> CNer ❑ Demnalirg cold and boosters ❑ With projectiles ewq ❑ W9iail projed9e <br /> ❑ <br /> Sealing MetaHal Neat Cemenr(9</b Dag]58 gel walelf Slad Cemenl we a*/)9M walM BA meft.Pelbta <br /> SentaMle(20%solid.) Manufadiuer Spec % Name Spas on File Spm Subrn lied <br /> Placement Mated Pumped Free Fell ry Oder <br /> Seal C.Pwwe COmplee.1,Muihnom Cap L- Sap COmpiete to Edsting S-Hace Ped <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND TNAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> JOAOUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE 1S <br /> CURRENT AND ACTIW WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> 'INIVU." Li.OUR AUVANCE NOME REOUf - 9013:14SPEC11ONS 1a� 2 <br /> CpVTMCTORS SiONGNRE TLE `G. I - Dan W-IO-1-J <br /> E5f' <br /> jjw� Ll <br /> bSOr <br /> welt +o PAYMENT <br /> gbcLY�donGA ECEtL�E'p <br /> C CT 10 2013 <br /> SAN J DAOUIN COUNTY <br /> Et VIROMENTAL <br /> HEAL H DEPARTMENT <br /> DEPARTMENT USE ONLY t�9 � <br /> AAptimOm Aaepled B Oata Area W �D U/QS <br /> Desbucaon Inspect on y Dale Employee I <br /> COMMENTS <br /> / Cct - /O // ] 40 wiCARWNIT <br /> PE SC ReeaNadv hKM/ Amount Pen°WInvoke• wall <br /> Cedes Inb �1 milted Smell, wNN <br /> EHO a308 WELL DESTRUCTION PFRMiT <br /> tYyO] <br />