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F ,LL.DESTRUCTION"PERI <br /> PU <br /> es No <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Rut <br /> 304 E WEBER AVE 3 FLOp=CCAr5224b8-34 • <br /> NON-REFUNDABLE PERMIT ( ) 20. \ <br /> CALL(209)953-7697 FOss.INSPECTIONS EXPI RES`1 EAR.FROivI DATE 1ssuED <br /> JOB ADDRESS 0z—O// P <br /> p <br /> Y/ZI " <br /> r OWNER <br /> PHONE — a <br /> a <br /> OWNER ADDRUS t �' CITY/STA El .1 8 <br /> I CONTRACTOR PHONE <br /> r <br /> �CONT OR ADDRESS CITV/STATE/ZTP -` <br /> 11 C-57 WELL DRILLING LICENSE NUMBER EXPIRATION DATE <br /> 1 <br /> PERFORATION CONTRACTOR PHONE <br /> r PERFORATION CONTRACTOR ADDRESS CITY/STATEIZIP <br /> 11 ❑ C-57 Well Drilling License Number Expiration <br /> Date' <br /> ❑ Bureau of Alcohol,Tobacco and Firearms-Users.of High Explosives License Number' Expiration Date <br /> ❑ CHP Hazardous Material Transportation for Explosives License Number Expiration:Date <br /> E3.,San Joaquin County Sheriff-Coroner Explosives Application and Permit License Number Expitaiion Date <br /> ❑ California Occupational Safety Health-Blaster License Number <br /> Expiration Date. <br /> ms <br /> REASON-FOR DESTRUCTION ❑ Dry ❑ Replacement Well ❑ "Caved In ❑ Pit Well .active 0 Test Hole <br /> Detected,/Suspected Well Water Contaminant(s): " <br /> Adjacent property with contamination (Address): <br /> Known Soil/Water contaminants at adjacent property; <br /> EXISTING WELL CONSTRUCTION DETAILS ❑ Open DOI ❑ Gravel Pack 0 Uncased ❑ Other <br /> Well Log copy attached p Yes "'Grout Seal .❑ No ❑ .Yes ft below ground surface(bgs) Hale Diameter inches ' <br /> r g�;,4inches.; <br /> Well Conductor Casing ❑ Yes- - ❑ No Depth of Conductor Casing - ft legs. Diameter of Conductor Casin <br /> C3 ell Casing Diameter 9inches Total Depth Depth to Water ft "Depth of Casing <br /> �pi <br /> I <br /> DESTRUCTION SPECIFICATION /� ` <br /> Sealing Material from ft bgs to!-/- ft bgs Filler Material from ftbgs;to ft bgs 1 <br /> Well casing to be Perforated b one of the following methods - <br /> �-- Y „� from ft b to ft bgs <br /> bgs " <br /> -- g <br /> ❑ Mills-Knife Number of cuts every ft and/or <br /> ❑ Explosives ❑ Detonating cord: ❑ with projectiles every ft lj without projectile <br /> ❑ Detonating cord and boosters: ❑ with projectiles every ft ❑ without projectile <br /> ❑ Otherzr <br /> Sealin' aterial 0 Neat Cement(94 lb bag J S-6 gal water) 13 Sand Cement sack mix 17 gal water [3 Bentonite Pellets <br /> Bentonite(20%soli d9s' D Manufacturer Spec%solids % NameQbZ J4Ar CJ—%pecs on File ❑. Specs Submitted Ga <br /> Placement Method T— Pumped ❑ Free Fall ❑ Other <br /> Seal Completion: iY'Complete with Mushroom Cap 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.- 1 ALSO-G>vRTIFY 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 /> 1Vi1Ni 2 OU ADVA CE NOTICE REQUIRED FOR 1 P1 CTIONS. <br /> CONTRACTORS SIGNATURE: TITLE: DATE: <br /> Ilk I'A <br /> EL kf, i <br /> 1.2 <br /> 1 <br /> i <br /> UEPARTM-ENT-"E"ON-LY' <br /> PP Accepted O� Area T �+p <br /> A 1ticahon Acc ted By Date .� I <br /> destruction inspection By Date LL r Employee[D# + <br /> 3 3 <br /> COMMENTS Q1 �C� <br /> ` )cry <br /> r C� <br /> PE SC Received eck#I Amount Permit! ,I <br /> Date Invoice# Well Ips i x <br /> Codes:: Info; BY Remitted 5ewice Reg uesf# <br /> So•.,ry <br /> ,,��� <br /> Gl7fp4 - -, Well AcaWdtlon��rry��crml A ",��t� L <br />