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i <br /> 17'-N,LL DESTRUCTION PERT ` <br /> PU � No \ <br /> U <br /> -SAN.IOAQUIN COUNTY ENVIRONMENTAL L HEALTH DEPARTMENT 344 E WEBER AVE 3¢u FLOOR c CA 5x42 - (209)AG8 320, i <br /> NON-REFUNDABLE PERMIT CALL(209)953-7697 FOilt INSPECT16NS EXPIRES 1 EAR�.FROM HATE ISSUED <br /> /y 3 <br /> 306 ADDRESS �eITY/ZIP <br /> Y <br /> oZ-`ZaL ' PHONE' ^ <br /> OWNER <br /> i f' CTPY/STA EIZI <br /> OWNER ADDR s <br /> CONTRACTOR PHONE <br /> CITYISTATE/Z1P <br /> �C_l <br /> 7C-57 <br /> OR ADDRESS <br /> WELL DRILLING LICENSE NUMBER EXPIRATION DATE �yyI <br /> PERFORATION CONTRACTOR PHONE 3 <br /> PERFORATION CONTRACTOR AD <br /> DRESS CITYISTATEIZIP <br /> ❑ C 57 Well Drilling License Number Expiration Date' <br /> Expiration Date I <br /> ❑ Bureau of Alcohol,Tobacco and Firearms-Users of High Explosives License Number P <br /> ❑ CHP.Hazardous Material'Tramportatiorr for Explosives License Number 77- <br /> Expiration Date <br /> ❑:San]oaquin County`Sheriff�Coroner Explosives Application arid-Pertnit License Number Expitation Date <br /> ❑ Califomia Occupational Safety Health-Blaster License Number Expiration.Date. <br /> REASON FOR DESTRUCTION ❑ Dry ❑ Replacement Weii ❑ Caved in ❑ Pit Well nactive 13 Test Hole <br /> Detected Suspected Well Water Contaminant(s): <br /> Adjacent property with contamination (Address): <br /> Known Soil I Water contaminants at adjacent property.; <br /> F . <br /> EXISTING WELL CONSTRUCTION DETAILS ❑ Open Bottom ❑ Gravel Pack ❑ Uricased ❑ Other <br /> Well Log copy attached ❑ Yes � No Grout Seal. .❑ No ❑ .Yes ft below ground surface(bgs) Hole Diameter mc4es:. <br /> Well Conductor Casing ❑ Yes. ❑ No. Depth of Conductor Casing - ft bgs. Diameter of Conductor Casing _inches <br /> (3Yell Casing Diameter inches Total Depth K�IA'+ Depth to Water. ft Depth of Casing bgs ;, ZV <br /> DESTRUCTION SPECIFICATION <br /> Sealing Material froft bgs.t �_ft bgs Filler Material <br /> from ft bgs to ft bgs.- <br /> Well casing to be Perforated by one of the following methods from ft bgs to ft bgs <br /> ❑ Mills Knife: Number of cuts every ft and l or <br /> ❑ Explosives '❑ Detonating card: 0 with projectiles every ft ❑ without projectile. <br /> ❑ Detonating cord and boosters: ❑ with projectiles every ft ❑ without projectile <br /> ❑ Other <br /> Sealin aterial ❑. Neat Cement(94 lb bag/5-6 gal water) ❑ Sand Cement sack mix 17 gal water ❑ Bentonite Pelletst <br /> E Bentonite(24%soli El❑ Manufacturer Spec%solids % Nam Uzi %� �e s on File ❑,. Specs Submitted G.�{ <br /> Placement Method R Plumped ❑ Free Fall ❑ Other 1 <br /> Seal Completion- #,Yr complete with Mushroom Cap�/F 6f/��l ft bgs ❑:Complete to Existing Surface Pad <br /> I 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.CS <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 2 OU ADV# CE NOTICE REQUIRED FOR 1 PECTIONS <br /> CONTRACTORS SIGNATURE; TITLE: DATE; <br /> I Al <br /> i <br /> V Q <br /> -. .. .-. <br /> Date 3 4� Arca <br /> Application Accepted By �J <br /> Destructi'onlrispectiosBy Date Employee ID114 <br /> CommENTS, /. Gal <br /> �c1 LAG cr[,a l�1ZY�f�i�r/'f'cc. P . � YY <br /> l G s.Gd� d <br /> PE SC Received eck#/ Amount Date Permit/ Invoice# Weli IIIA Y <br /> Codes. Info 7 B s Remitted Service Request# <br /> Q <br /> � -' � Wcll�csVud7on'I�crinit JS,¢tf4 �S16 <br />