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WELL DESTRUCTION PERMIT " <br /> PUB❑C WATERSYSIEM O Yes ❑No <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMEM 304E WEBER AVE 3"FL-STOCIION CA 95203 -(309)46$-3430 <br /> NON-REFUNDABLE PERMIT p A/LyL f2 9)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR P DATE ISSUED <br /> JOE ADDRES6 E- N CITY/ZIP <br /> D <br /> 0`3 'Eecyl <br /> CROSS STRECr APN PARCEL SI LAN USE A�PPI/�/CATION <br /> /O�/ '1 � <br /> OWNER PHONE - <br /> OWNER ADURPS hal.It A A 1 6 CDY/STATEf7JP <br /> CownusROR 11WI / PHON <br /> CO CTORADDRESS - l CITY/STATFILIP �C <br /> C-57 WELL DRILLING LICENSENOMBER EXRRATION DATE <br /> PERFORATION CONTRACTOR PHONE <br /> PERFORATON CONTRACTOR ADDRESS CMISTATE17AP <br /> ❑ C-57 Well Drilling Liceae Number Expiration Date <br /> ❑ Bureau ofAlcohol,Tobacco and Fimms-Users of High Explosives License Number Expiration Date <br /> ❑ CHP Hazardous Material Transportation for Explosives License Number Expiration Date <br /> ❑ San Joaquin County SheriRLomner Explosive Application and Permit License Number Expirstion Date <br /> ❑ Celifomia Occupational Safety Ialth-Blaamr License Number Expiration Das <br /> REAdON FOR DEsrRUc ION ❑ Dry ❑ Replacemrnt Well ❑ Caved In ❑ Pit Well Inactive ❑ Test Hole <br /> Detested/Suspected Well Water ContaMuant(s) <br /> Adjacent property with contamination (Address) <br /> -•Known Soil I Water contsminaots aradjacent property <br /> EXIMNG WELL CONS]HRUCTIlIMPLIAW ❑ Open Bottom Gravel Pack ❑ Uncawd ❑ Other <br /> Well lug copy attached ❑ Yeso Grout Sal ❑ No ❑ Ye B below ground surface(bgs) HolaDiameter inches <br /> Well Conductor Casing ❑ Ya VN. Depthof Conductor Casing Bbga Dlasrleterof Conductor CaalRg inches <br /> Well Casing Diameter_ inch. Total Depth jB Depth to Water R Depth of Casing B bga <br /> DMIR) i'ION SPECIFICATION <br /> Scala,Material from It bgs In:W A his Pifer Material fromfit fags to B bgs <br /> Well cuing to be verformund by one of the following methods: from R bila to R bas <br /> ❑ Mill,Knife Number ofeuta every Rand/or <br /> ❑ Explosives ❑ Dcmnatingeord ❑ withpmjaUl.every B ❑ withotaprojeetile <br /> ❑ Demnuing cord and boosters O withpmjaUlesevery N ❑ withoutprojectile <br /> ❑ Other <br /> Beall sterid ❑ Neat CmN.t(94fhbW15-dge1wAAeJ ❑ Smd Cement sackma17gr}water ❑ Bentonite Pellets <br /> eentonile(20 <br /> % ds) ❑ ManufacturerSpec%solids % Nome AWO-48ge }7¢ Fecs on File ❑ Spa.Submiued <br /> Placement Method�Jp�mped ❑ Free Fall ❑ Other <br /> Seal Completion `ff'Camplete with Mushroom Cap B 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. I 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 /> I M M 24 YJUR AD'ANCE NOTICE REQUIRED FOW INSPECTIONS <br /> CONTRA RS SIGNATURE TITLE DATE O <br /> ell <br /> p,�Y 1�1E,1i <br /> u�Cf fVC�? <br /> NOV � 0 2006 <br /> ® L <br /> S dOAQUIN COUNTY <br /> ENVIRONMENTA- <br /> HEALTH DEPAMMENIT <br /> '— --" - -- EP- RTMENT USE ON <br /> y -�-aF-as�- <br /> Appiicati nAcc <br /> epted Dam O GfiT� Ara <br /> Deshucti Insp tion Dam Employee IDN <br /> vas �rinv <br /> COMMENT$ <br /> PE SC R.dved Ch.YX/ Amount Date Permit/ InvalaN Well ID# <br /> Coda Info B ReMHed Service Repeat is <br /> 3 b h o 010 <br /> Soo <br />