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///VYI 10/6S jt <br /> //.,(-,fir.' I <br /> WE' DEST,�cR,prUcCTION PERMIT <br /> ' W, O6I - Lqt- C�` \ " 7 PUBLIC WATER SYSTEM Yes P(No._ <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE 3"FLOOR-STOCKTON CA 95202 - (209)4OW3420 <br /> NON-REFUNDABLE /PEr/RMII7T'� CALL(209)953-7697 FOR INSPECTIONS /1 EXPIRES I YEAR FROM DATE ISSUED <br /> JOBADDRESSC <br /> �TGL -s'-� _ �J/J CITY/ZIP <br /> OWNER�� Plerl7 4 PHONE �/ 7C <br /> OWNERADDRESS ��/�lI ^��� CITY/STATE/ZIP —C �4 !Zfc DI9, k^_ <br /> CONTRACTOR <br /> cAL 61/6ume I���VCi PHONE 3�✓.i– l / 1D! ,lal L' <br /> CONTRACTOR ADDRESS 57 CITY/STATFIZIP CeR <br /> 0—C-57 WELL DRILLING LICENSE NUMBER EXPIRATION DATE•� `�� <br /> PERFORATION CONTRACTOR S PHONE <br /> PERFORATIONCONTRACTORADDRESS CITY/STATE/ZIP <br /> 0 C-57 Well Drilling License Number 41/y Expiration Date _ <br /> ❑ Bureau of Alcohol,Tobacco and Firearms-Users of High Explosives License Number Expiration Date 'nil <br /> ❑ CHP Hazardous Material Transportation for Explosives License Number �m'yyrBB[tIon Date <br /> ❑ San Joaquin County Sheriff-Coroner Explosives Application and Permit Lice y fp tion Date 'tJ' <br /> ❑ California Occupational Safety Health-Blaster Lice TTjj'' xpr tion Date t�^ <br /> REASON FOR DESTRUCTION ❑ Dry ❑ Replacement Well ❑ Caved In ❑ Pit Well Inactive ❑ Test Hole <br /> Detected/Suspected Well Water Contaminant(s): F <br /> Adjacent properly with contamination (Address): ,fm <br /> Known Soil/Water contaminants at adjacent property: (OW <br /> n <br /> EXISTING WELL CONSTRUCTION DETAILS ❑ Open Bottom ❑ Gravel Pack ❑ Uncased ❑ Other k1&A0AWd0W Nu <br /> Well Log copy attached ❑ Yes ❑ No Grout Sed ❑ No ❑ Yes R below ground surface(bgs) Hole Diameter ,jpches. <br /> Well Conductor Casing ❑ Yes ❑ No Depth of Conductor Casing ft bgs Diameter of Conductor Casing .:illphm <br /> Well Casing Diameter—f—inches Total Depth B Depth to Water _it Depth of Casing kbp rr4— <br /> DESTRUCTION SPECIFICATION IHH ' <br /> Sealing Material from ft bgs to it bgs Filler Material from fl bgs to fl bgs <br /> Well casing to be perforated by one of the following methods from ft bgs to ft bgs 1't] <br /> ❑ Mills Knife Number of cuts every ft and/or .9 <br /> ❑ Explosives ❑ Detonatingcord: ❑ with projectiles every ft ❑ without projectile <br /> ❑ Detonating cord and boosters: ❑ withprojectileseveryft ❑ withoutprojectile <br /> ❑ Other <br /> Sealing Material ❑ Neat Cement(94 lb bag 15-6gat water) ❑ Sand Cement sack mix/7 gal water O Beotoolle Pellets <br /> Bentonite(20%solids) ❑ Manufacturer Spec%solids % Name Cl Specs on File OSpecs Submitted. Y <br /> Placement Method ❑ Pumped ❑ Free Fall ❑ Other <br /> Seal Completion: ❑ Complete with Mushroom Cap ft bgs ❑ Complete to Existing Surface Pad <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 IS <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> t <br /> MINIM 2 Ol R ADVA CE NOTICE REQUIRED FOR SPECTIONS <br /> CONTRACTORS SIGNATURE: TITLE• G / DATE: <br /> Fit <br /> I- <br /> ear. � c <br /> tall Ct..,,,�• - <br /> U � I <br /> PARTMENT USE ONLY "h� G <br /> Application Accepted By Date D L Area ti�� <br /> Destruction Inspection By <br /> Date C7 s Employee ID# e! <br /> COMMENTS Wad 6✓ S <br /> .,art;. <br /> PE SC Received Check#/ Amount PeemlV <br /> Codes D <br /> Info R Cash Remitted ate Service R uest# Invoice# Well IDN <br /> l � �J <br /> EHD 0-02-MR CGI �� Well D tmcivn Pcrmi,AddcMum,1604 R&x-01 <br />