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U WELL DESTRUCTION PERMIT N...6 � <br /> PUBUCWAURSYSIEM DY.xc <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 WEBER AVE 3"FL-STOEKTON CA 95202-(209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL(209)955-7697 FOR INSPECTION'S EXPIRES 7 YEAR FROM DATE ISSUED <br /> JOB ADDREM 230E CITYf/.IP�yit <br /> i <br /> CROISSTREF.TT r1 APN 007-3ft -M PARCELSI]l3_LAND USE APPLICATION N 0 <br /> OWNER A — /J!L/J PHONE 7O 7 - _77r <br /> OWNER ADDRESS I - B CITVISF TEIZ' Jiw VIF:EL <br /> 727 <br /> CONSRACIoa /1.o-T-�d /JrAi w�_P../r /J�'�� PHOrve B - fZ <br /> ,�44 <br /> CONTRACTORADDREES /OOp ` %4Y MOPtIRN r CITV/STATIclup x C-57WELLDRRPNC LICEENSSENUMBE0. T J EXPIRATIONDATC O <br /> PERFORATION COWRACOR *_� �' A-4'S PHONE � I <br /> PEIIFONATION COMMCt'OR ADDRESS .;TATr- <br /> C-57 Well Drilling License Number LI!$,fSSy Expiration Date 7 0 <br /> Clsr <br /> BorrauofAlcohoi,Tobacco and Fiiama-Users of High Explosives License NumberExpiration Date <br /> ❑ CHP H.E ders Material Tnnspormhon for Explosive U...Number Expiration Date <br /> ❑ San Joaquin County Sheriff-Coroner Explosives Application and Permit Ucwne Number Expiankm Dale <br /> ❑ California Occupational Safety Health-Bianer License Number Expiration Dam <br /> REAsnIN vOR DESPERUMON ❑ Dry, ❑ Rcpiecement Well ❑ CavW In ❑ Pit Well Inactive ❑ Tat H.I. <br /> Detected/Suspared%41 Water ContamlmmH <br /> Adjacent property with contamination(Address) <br /> Known Soil/Water canto rd...ls al adja.cm property <br /> t <br /> PXISG WELL CONUSUMION DETAILS ❑ Open Bottom - ❑ Gravel Peck ❑ U...sed ❑ Other ` <br /> Well LogcopY.etmchW ❑ You ❑ No GaRl Seal ❑ No ❑ Yes ftbelowgroundsuffece(bp) HoleDiameter inches <br /> Well Conductor Casing ❑ Yes Cl No Depth of Conductor Caeln{ ftbp DhmNHror Conductor Cad.x inches <br /> Well Casing Diameter 17_inches Total Depth 5'00 ft Depth to Water ft Depth of Cuing R bgs ta <br /> 4 D mr'CF SPECIFICATION <br /> I'• <br /> Seth,M.Wral from 100 fibpto 3 Rbp Filler Materiel from .5-00 ftbpm COO ftbp <br /> Well casing to be verforaled by am of the following methods: from !00 ftbp 10 S ftbp 4 <br /> ❑ MKI.Knife Number of cuts every Rend/or ?.1 <br /> �KExplaslves ❑ DrumatingcoN ❑ withprojoetilesevery ft ❑ withoutprojectile Z <br /> ❑ Dakm;Ungcordand!;:m ❑ ith jcctikRevery ft ❑ withoutprejectile <br /> 1 ❑ Other /OCJ �L'•F L_��-f9 wt <br /> Sealing Material ❑ Nut Cement(9J/hhHg15dgulwar 1 Sand rte 1D..3 arrk Die/7 gal to, ❑ eemonite Pellet. .1 <br /> ❑ Beoboite(20'/solids) ❑ Manufacturer Spec'Kaolide_% Name ❑ Specson Filc ❑ Specs Submined <br /> Placement Meflu p Pumped ❑ Free Fail ❑ Other l' <br /> Seal Completion 4 <br /> Complem with M.A..Cap -3 ftbp ❑ Complete m E.10log Surface Pad U <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. 1 ALSO CERTIFY THAT MY REQUIRED LICENSE 15 <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT 1 AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> ' NMl IMUM IA ROIJR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br /> CONTRACTORS SIGNATURE; TITLE B�/I-+4.✓ DATE <br /> EL <br /> lac J <br /> FAYNINT� <br /> _ ERED;_ � <br /> i 1 <br /> U --- T-- <br /> - _ I _ �J AO11 I )ZZ <br /> !!'' ..,- - • : IJJVIFiONMENTAL , <br /> — I - � HEALTH DEPARTMENT-.I--•__ <br /> --T I I <br /> T 1 j <br /> DEPARTMENT USE ONL T <br /> Application Acc,trd By Date <br /> -�r _� <br /> !O Q Aree <br /> Dmnuction lnapa.lion y Data Employee IDM s3(P(0 <br /> COMMENTS <br /> PE SC Received Che, Amount Data Permit/ InvolaM Well IDM <br /> Cadet Info B Cash emitted SerHaR ueat# <br /> 3-7 llpS Cir 5 afT' 1 PO 22� <br /> Elm acus-wx <br /> Well�6­Na <br /> taraas <br />