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APAI '20?04302�— WELL DESTRUCTION PERMIT <br /> PUBLIC WAM SYSTEM Qyea C]No <br /> SANJOAQL�INCOUNTYErYIRONMETTkTA4HEALT11DEpggTMEIY'[' <br /> NON-REPUNDA E PERM.-PI <br /> SAN <br /> WEBER AVE 3"`Fl-DOR-STOfKTON CA 95202 - (209)468.3420 <br /> CALL(209)953-7697 FOR INS PEcrIO�s EXPIRES 1 EAR FR RATE ISSUED <br /> Joe ADDakss -' <br /> OWNER n CrTy' li! <br /> PHONE n <br /> OWNEa ADDRFSS > <br /> CI]VSTA_ '� a <br /> CGNTgwcTOa PHONE W//�_ <br /> 7'" '• <br /> CD CTOR ADI } � �� qq <br /> 2 `t r t <br /> C37 WELL DRILL2NC LICENSE NllMaEq U1CITY/STATFJZIP <br /> EXPIRATION DATE I <br /> PERFORATION CO!rraACTOR <br /> PERFORATION CONTRACTOR ADUAESg PHONE <br /> CITUISTA.FF <br /> ❑ C•57 Well Drilling JZIP <br /> ❑ Bureau OfAlCohol,Tobacco and Firearms- License Number Expiration Date <br /> Users Of HighF,Aplosives LtcenseNumber <br /> C7 CHP Hazardous Material Transportation for Explosives ��- Expiration Date <br /> 11San Joaquin Coun ry Sh p Lcense Number` pxpiretian Date <br /> ttiff-COrontt Explosives Application and permit License Number <br /> ❑ California Occupational Safety Health-Blaster �—License Number Expiration Date <br /> REASON FOA DESTRUCr[aN -� FKPiradon Date <br /> Dry ❑ Replacement Wel! ❑ Caved to ❑ Pit Well -1 <br /> Detected l Suspected Wall Water Contaminant(a}: nactice {] Test HOlc <br /> Adjacent property wilh eontamiaalion(Address). Q <br /> Known Soil!Water contaminants at adjacent property: "41� <br /> E%aATeNG WELL CONMUCTION DETAILS [3 Open Bottom ❑ Uravel Pack <br /> WrBd CrLogcOpyattacheYes ❑ Uncayed ❑ Ocher <br /> No Grout Seal r) No ❑ Yes A below ground surface 6 <br /> Well Conductor Casing Cl yea ❑ No Depth of Conductor Casing R b (gs) Hole Diameter inches ( w <br /> Welt CasingDiameter &s Diameter Of Conductor Caslaa inches vl <br /> inches Total Depth�-ft Depth to Water t <br /> Il Depth of Casing, g bgs <br /> DFSTRUCFIO.4 SPECIFICATION l <br /> Sealing Material from AMAY91g bgs tp�ft bgs <br /> Filler Material from <br /> We11 casiog to be perforated by a Df the folloWlna from ME±2,s n bgs to ft bgs <br /> C] Milh Knife R bgs to fl bgs <br /> Numberofeuts every ft and Ior <br /> ❑ ExploI ❑ Detonating cord: ❑ with projectiles every ft (, <br /> 13Mranating cord and boosters: 17 with projectiles every ft ❑ without projectile <br /> ❑ Other ❑ without projectile <br /> Sealiag Material ❑ Neat Cemeat(941h hag/3-hgal urrrer) Sand Cement <br /> ❑ Bentonite(20%solids p M �adck mix/7 gal water ❑ Bentonite Pellets <br /> 1 anufhensrer S�cc%solids °h Name <br /> Placement Method ❑ Pumped �'Fm Fell Cl Other ❑ Spocs on piEe ❑ Specs Submitted <br /> Seal completion. 00' COmplEw with Mushroom Cap_CrA1AwJT it bps <br /> ❑ Complete to Existing Surface Pad <br /> I HEREBY CERTIFY THAT 1 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 /> MINI M 4 OUR A VANCE NOTICE REQUIRED FOR INSPECTIONS <br /> CONTRACTORSSIGNATURE: <br /> TITLE' A DATE: <br /> Wffi� . <br /> 1 <br /> \ \ 1 PAYM!:tN'? , <br /> RVC,FtVEG- <br /> NOV 17 2005 <br /> SAN JOAQ61N COUNT! <br /> ENVIRONMENTAL. <br /> HFJILM DEPARTMENT <br /> DE ARTM T USE ONLY <br /> Application Accepted By <br /> Date Area <br /> Ueatruetion inspection E 'D. 9 <br /> Date `� mployee <br /> COMMENTS I <br /> I � <br /> Ir <br /> PE SC Received hY <br /> Codes It Amanot Permit/ <br /> B Cash nn Remitted Data Service Request N Invoke R Well IDI. <br /> L <br /> FJR)"-p2-Oa.VVL- F <br /> 5 <br /> aj <br /> f/ � //C..`(� tI✓ 1 G�Q4� /� �/4" �U..p�. , 7�. V/t PCAlupion PCryail Addendulp 4/-061e�5#.97 <br /> V Ir - c�4 !V%l OY\ St-fCrl_I <br />