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iv ios- as-3 <br /> WELL DESTRUCTION PERMIT <br /> PUBLIC WATERSv51EM ❑Ya 9No <br /> SM JOAQUIN COUNTY ENVIRONMENTAL I@ALTR DEPARTMENT 304E WEBER AYE 3"FLOOR-STOCKTON CA 95202 - (309)468-3018 <br /> NON-REFUNDABLE PERDf1T CALL(209)953-7697 FOR INSPECTIONS EXPI RFS I YEAR FROM DATE ISSUED <br /> JOBADDRESS l 07.61 S. 7hflC7lj�f[F /�� _cmrtlr, ( � !„A <br /> OwNSK_ vr5'-L3U !PRONE __ e <br /> OWNERADORE SAQy� '/.S(L P'.. — O <br /> Cm/STATr Zrp <br /> COMAACTOR_ `RL /� / Gq i1a�ILL/A/l iyL PHONY.. 467-7-lalL <br /> CON/TIGET(n' DDRESS 3OD S• �/[ CiN/$fATE/ZII �� <br /> IT C-57WEu,DRauvO LICENSCNUMBER� �4� E%PIRATION DATE <br /> ;14 Ir— <br /> Pineyealitunwee CDNTRAt OR PHONE <br /> PERPORATION CONT (T RADDAES9_ Cri-y SrAI'EIZir <br /> ❑ C-57 Well Drilling Liunm Number Expiration Date <br /> ❑ Hureau ofAlc9hol•Tobacco and Fhurms-Users of High Explosives License Number Expiaden Dau <br /> ❑ CHPilamrdum Maurial T.anspamtionrur Explosive License Number Fxpiytion Date <br /> ❑ San loaquin Colmty SherifTCOmner Explosives Apphcalmn and Permit License Number Expiration Date <br /> ❑ GI Shoals Oacupational Safety Health-Blostar License Number Expiration Date <br /> REASON POR DrSMECr1ON Dry ❑ Replacemyt Wdl ❑ Caved In ❑ Pit Well <br /> G Inactive Cl Tut}tole <br /> Detected/Suspaled Well Water Contertaan[(a): <br /> Ad)awntpropertywithronhmina Hon(Addles): <br /> KnO.ra Sod I Weer..to mi name at adjacem pmpeny: <br /> E.rIM%UWE"CONSTRIJ"IONDETMR/Cl Open Bottom 13Ouvd Pack ❑ Unused &'011er U ,IWA40* <br /> Well Logeopymtached ❑ Yn � NN Groot Seal E3 No C3 Yen__ n below ground surface(bgs) Hole Diameter _ _ inches <br /> Well Condenser Cas ❑ Ya fS No Depth of Conductor Caring P.bels Diameter of Conductor Casin¢ Trachea <br /> Wall Calling Dfi nwur__inches TDtoI Depth_ ,r R Mink to Water�j_R Depth of Casin¢ 1�� ft bels •per. <br /> DESTRUCOON SPECIFICATION V <br /> Sealing Material from 0Bbgsto nbgs Filler Material tram ftbgew ftbgs -(I <br /> Well casing to he perforated by one of the following methods from _R bgs to it been A' <br /> ❑ Mills Knif< Numbv of cuts every nand/m I_ <br /> ❑ Explosives ❑ Demnalingeord: ❑ withpmj.dlynvery n ❑ wilhoutprojeeile <br /> ❑ .Demnmingcordandboustee: ElwiN pmjecHle every fl 13 vnmDurprojectue <br /> ❑ Other <br /> Selling Mm en.1 ❑ Neu Cement(94 h Avg/5-A gni wOrer) ❑ Sapd Cement_mack wLc/7 gal water Bentonite Pellcts <br /> ❑ Bentonite(20%solids) ❑ Manuflmumr Sgg''�cXaolida_Y. Name ❑ Speeson File ❑ Specs Subround <br /> m <br /> Placeent Method 13Pumpod ;no Fall ❑ Other <br /> Seal Completion: B�Cumplmc w'h aaxhrao C p_ .3 t bgs ❑ Comple c to Exiadng Surface Pati ('1 <br /> I HEREBY CERTIFY THAT i HAVE PREPARED THIS APPLICATION A D 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 I <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT 1 AM IN COMPLIANCE WITH ALL TI <br /> WORKERS COMPENSATION LAWS. O <br /> /(�ehf MINIM N H UR AD NCE NOTICE REQUIRED FOR SPECTIONS rn <br /> '.. CONTRACTORS SIGNATURE: TITLE• DATE: <br /> 57 - <br /> I� <br /> DEPARTMENT USE ONLY q <br /> Application Accepted Hy Dace I c"5- y <br /> Ar <br /> Duwetion Inspection H Due---- Fmployy IM tf <br /> COMMENTS <br /> PE SC Retdved Chic Amount PermiB <br /> Cotly Info B sato RemlRed Dau IvvOiceA N'eII IIM� <br /> Service Re uyt8 <br /> [SL'}.oJpy(il�' ID4 <br /> / CQ �I C/S�.�I. <br /> EHDO.OI WF �jr�l/���I�II�-/� �O�aeWJ �L���G�r-Q�G.• <br /> I r✓r'M �� �/ _I WallWuron Pwmil AtlG'um aMal.AXau <br /> 4J� <br />