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................... ....... ----------- <br /> 2 <br /> WELL DESTRUCTION PERMIT 7X? <br /> PUBLIC WATER SYSTEM C]Yes&M <br /> SAN JoAoum CouNrry ENVIRONMENTAL HEALTH DEPARTMENT WO E MAIN STREET-STOCKTON CA 95202-(209)"0-3420 <br /> NON-REFUNDABLE PERMIT CALL(209)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> m <br /> Joe Aoo- 36 tlz�vj C.'alp a ±>-"111� <br /> CROSS STREET f"", APN PARCEL SIZE C'N.AND USE APPLs--A`n0N# <br /> OWNER FluJ PHONE t - <br /> r. <br /> OWNER ADDRESS —ClTY1STATiYZiP <br /> CONTRACTOR PHONE -A2!i <br /> Co..A..MC CaYISTATEIZIP e-a <br /> '? <br /> a-I'C'-57 WELL DR&LtNG LICENSE NUMBER FxptRAT*N DATE <br /> PERFORATION CONTRACTOR PHONE <br /> PERFORATION CONTRACTOR ADDRESS CITYISTATErIP <br /> • C-57 Well Drilling License Number Expiration 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 /> • Son Joaquin County Sheriff-Coroner Explosives Application and Permit License Number Expiration Date <br /> • California Occupational Safety Health-Blaster License Number Expiration Date <br /> ReASON l-DESTRUV09N 0 Dry 0 Replacement Well 0 Caved In 0 Pit Well 2--thaic" 0 Test Hole <br /> DerectediSuspected Well Water Contaminant(s) <br /> Adjacent property With Contamination(Address) <br /> Known Soil/Water contaminants at adjacent Property,,__. ..................................... <br /> ............ <br /> Eli"11104 CONSTM&IVS ORTAU 0 Open Bottom 0 Gravel Pack 0 Uncased 0 Other­.­______­­_. <br /> Weil Log copy attached 0 Yes 0 No Grout Seal 0 No 0 Yes ...............V below ground Surface(bgs) Hole Diameter inches <br /> Won Conductor Casing 0 Yes 0 No Depth of Conductor Casing--It bgs Diameter of Conductor Casing._'-has <br /> Won Castrill Diaffww.__L,__inches Total Depft�,� &it Depth to Water....................---ft Depth of Casing ft t91 <br /> 00 Spec"WAT*k i <br /> Sealing Material from. it bgs,to it bgs Filler Material _. frOf . it to <br /> ....... it bgs <br /> n bgs <br /> Well Casing to be gerfoglod by one of from it bgs to---ft bgs <br /> • Mills Knife Number of cuts every -- <br /> • Explosives 0 Detonating cord 0 YAM projectiles every­­_it 0 Without Projectile <br /> 0 Detonating cord and boosters 0 with projectiles every_,.,,_._it 0 without projectile <br /> ............... <br /> SaalingMaterlat ::: Neat Cement(94 lb bagl—lflgaiwater)2 Sand Cement Sack mbu7 gal Water ,Bentonite pellets <br /> Bentonite(20%solids) -' Manufacturer Spec%solids _% Name � Specs on File Submitted <br /> Placement Method je- Pumped Free Fall_ 4:-, Other AZZr— -r, C/Z—,i, <br /> Seal Completion L 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, 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 /> MI UM 2d�HIANCE NOTICE REQUIRED FOR INSPECTIONS rq <br /> CONTRACTORS SMATURE TITLE DATE <br /> DEPARTMENT USE ON <br /> Application Accepted B Elate -t. Area <br /> Destruction Inspection <br /> Date Employee ID# <br /> COMMENT <br /> -Ve <br /> PE i SC 1 Received <br /> parmili <br /> Date Invoice 4 WIWI ID# <br /> Codes into By i Cash Remit service Request <br /> EH0 431-08 WELL DESTRUCTION PERMIT <br />