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P57-1 WELL DESTRUCTION PERMIT <br /> PUBLICWATERSYSTFJN❑Y-$No <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WESER AVE 3-FL-STOCKTON CA 95202-(209)468.3420 <br /> NON-REFUNDABLE PERM C. L(209)953-7697 FOR INSPECTIONS EXPIRES YEAR FROM DATE ISSUED r <br /> y <br /> 72• E. F 1 '� CITYILIP �' <br /> J ADDRESS _ <br /> CROSS ET <br /> APN r' '-Ll Sj /..C>; PARCEL SIZE_ ND USE APPLICATION# <br /> _ PHONE <br /> OWNER <br /> CrrYlST Zt <br /> OWNER ADDR _ <br /> rPHONE CONTRACTORCITVISTATFJZIPCONTRACTOR ADDRE -�C-ST WELLDRILLINC L_lCEN5ENUMBER1EXPIRATION DAIF;; <br /> PHONE <br /> PERPORATION CONTRACTOR . <br /> CtTYlSTATElZlP - <br /> PERFORA ON CONTRACTOR ADDRPSS <br /> �' I Ixn <br /> C-57 Well Drilling se Numtier ,, r� Expiration Date <br /> License Expiration Date <br /> ❑ Bureau-of Alcohol,Tobacco and Firearms-Users of High Explosives Expiration Date <br /> E3 CHP Hazardous Material Transportation for Explosives License Number <br /> ❑ San Joaquin County Sheriff-Coroner Explosives Application and Permit License Number Expiration Date <br /> C3 California Occupational Safety Health-Blaster <br /> .License NumberExpiration Date <br /> RE.SON POR DESTRUCHON ❑ Dry ❑- Replacement Well ❑ Caved In [3 Pit Well Inactive 13 Test Hole <br /> Detected I Suspected Well Water Conteminant(a) <br /> Adjacent property with contamination(Address) . <br /> Known Sail!Water contaminants at adjacent property <br /> t WE N DEt•AILs ❑ Open Bottom ❑ Gravel Pack ❑ Uncased OtherV�d't*� w <br /> Well Log copy attached f] Yes �7o Grout Seal O No ❑ Yes ti below ground surface(bgs) Hole Diameter inches art <br /> �I ft'bgs Diameter of Conductor CaaingJ^inches <br /> Well Conductor Calling ❑ Yes No Depth of v n o Dg ti <br /> Well Casing Diameter—10--inches Total Deptll R Depth Io Water ft Depth otCasing ft bgs <br /> RU N SPE TION <br /> Sealing Material from LQO . ft bgs to:7VP—ft bgs Filler Malerial .519rfID _ from ft bgs to�nD ft bgs <br /> WTl <br /> ling to be rated by one oft II in methods: from ft bgs to R bgs <br /> Mills Knife 100 FT--S>`)�umbe o cuts every - and/orExplosives ❑ Detonating cord O with projectiles everyft ❑ withoutprojectile <br /> ❑ Detonating cord and boosters ❑ with projectiles every ft ❑ without projectile <br /> ❑ Other <br /> Sealing Material ❑ Nest Cement(941bbag/J-6 gat waren) Sand Cement .�sack mix!7gal water ❑ BentonitePelkts <br /> ❑ Bentonite(20%y Ods) Q Manufacturer Spec%solids % Name [3 Specs on File O Specs Submitted <br /> Placement Method�Pumped ❑ Free Fall ❑ Other - I <br /> Seal Completion l-Complete with Mushroom Cap It bgs ❑ Complete to Existing Surface Pad <br /> 1 HEREBY CERTIFY THAT[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 1 AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> !MINIM M 4 HO ADVANCE NOTICE REQUIRED F INSPECTIONS <br /> CONTRACTORS SIGNATURE T E DATE <br /> -- T- <br /> AX <br /> M <br /> EN <br /> - . • _ f... RECEEVF <br /> tdlA� <br /> {� E _ <. .. <br /> sAT1 laAOu1N45OLI lTY. <br /> r1 fr. i Nvl�os�M�NT <br /> AL, <br /> EFA M- T <br /> IPEPARTMEN-T US-E ONLY -f - — ---- - - <br /> Application Accepted By pate �`�((') Area r <br /> Dcstmcdon Inspection By Date C7 i >:mployee 1D#, �Y �/ <br /> COMMENTS+ a� r'. ' AZ d S' 2 'Lj ! S .-n ✓r k 17 ti ) 452 <br /> 1 <br /> PE SCReceived ecldi- Amount Date Pcrmitl Invoice# Well IDN <br /> Codes Into By emitted ServlceR uest# <br /> i <br /> 2-10.1 3 0 <br />