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WELL DESTRUCTION PERMIT '76C <br /> 4v PUBLIC WATERSYBTEM ❑YEa`p <br /> SAN JOAOUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT BOO E MAIN STREET-STOCKTON CA 95202-(209)468$020 <br /> NON-REFUNDABLE PERMIT AL 20(91 953,A97 R INSPECTIONS EX RES 1 YEAR FROM DATE ISSUED <br /> JOB AODRES$ C I CMRIP �(. L <br /> CRO$$$TREET a� APNDI/"LQS/V PARCELS-av-' c--DrUSEAPPLICATION# a <br /> OER /�e ( •�d` <br /> WXQLI PHONE <br /> OWNER ADDRESS CITY/STATE21P / D <br /> CONTRACTOR, �Y ���, PPHONE re, <br /> CONTRACTORADDRESS rX4') In CnY/STATE P <br /> C57 WELL DRILLING LICENSE NUMBER_ /O Z2 EXPIRATION DATE 6 29 <br /> RFORATION CONTRACTOR PHONE M1 <br /> PERFORATION CONTRACTOR ADDRESS CITY/STATE/LIP Vf�A <br /> ❑ C-57 Well Drilling License Number Expiretion Date ate <br /> V <br /> ❑ Bureau of Alcohol.Tota.and Firearms-USeM of High Explosives License Number iration D <br /> ❑ CHP Hazamous Material Transportation for Explosives License Number EExpVmEu n Date <br /> ❑ San Joaquin County Sheriff-Coroner Explosives Application and Permit License Number Expiration Date <br /> ❑ California Occupational Safety Health-Blel License Number Expiration Date <br /> RE130N FOR DESTRUCiI ❑ Dry ❑ Replacement Well ❑ CavedU �OPAWNI nactlw ❑ Test tble <br /> Detected/Suspected Well Water Contaminant(.). <br /> Adjacent Property Adh Contamination(Address) <br /> Known SOiMaler contaminants at adjacent property <br /> Ex1¢TING WELL CONSTRUCTION DETAILS ❑ Open Bost. ❑ Gravel Pass: ❑ Uncesed ❑ Other <br /> Well LOS copy atached ❑ Ye¢ ❑ No GreutSwl ❑ No ❑ YBs flbelowground SUdace(bg8) Hole Dian; Inches <br /> Well Conductor Casing❑ Yee ❑ No Depth of Conductor Cal ft bgs Diameter of Conductor Casing inches <br /> Well Casing Diameter ff inches TWI Depth„u <br /> It DIP,Ls Water-_Z�fl Depth ofCuln9 flbga <br /> DESTRUCIDO PECIRCAMN <br /> Sealing Material from�'Q to ft bgs Filler Material hom It bgs to ft bgs <br /> Well Casing to be perforated by Ona of the bllowino chavithruch, from CLAS eveft bgs to ft bgs <br /> ❑ Mills Knife Number Of Lury every-ft <br /> ❑ Explosives Detonating Cold ❑ coir pmjectllas every fl ❑ without projectile <br /> ❑ Detonating Lord and boosters ❑ coir projectiles awry ft E3without projectile <br /> ❑ Other <br /> Sealing Material)( NeH Lament(9416 bap/3-8 gel water)❑ Sand Cemern sack miz/1 gal water Bentonite Pellets <br /> Bentonite(20%solids) o Manufacturer Spec%solids_% Name ❑ Spa¢on Flle Specs Submitted <br /> Placement Method o Pumped $t F4Fall Free ❑ Other <br /> Seal CompletlOn� Complete wtN Mushroom Cap d _ ft bgs p( Completa to Existing Surfaw 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 /> 24 HOUR CE NOTICE REQUIRE OR INSPECTIONS <br /> CoHTiumal 9SIGNATURE TITLE L re J Dsi <br /> ATE <br /> 5�P <br /> f � <br /> 100(I EIVED <br /> G 10D r 1 6 2008 <br /> S JOAQUIN COU <br /> /� VI11 NMEN7 INTI' <br /> DEPS <br /> DEP NT USE ONLY, <br /> ApplicationAccepted By Data <br /> Dastructlon Inspection i Area <br /> Date 7/dam Employee ID# s <br /> COMMENTS <br /> RE SC Received Check* Amount Owner ParmlU <br /> Cod" Iii By emitted Service IS Invoice• WNI IDM <br /> 1 DSO /Sri. 6 0 <br /> EHD 4408 <br /> i WY07 WELL DESTRUCOCN PERM r <br />