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AIR LZ <br /> -_P CEL SIZE JsE APPLICATION#---.-. <br /> OWNER.- <br /> 7d- c— ;!Z <br /> OWNER ADDRESS CITYISTATE/ZIP <br /> CONTRACTOR <br /> PHONE 7 <br /> CONTRACTOR ADDRESS <br /> E) C-57 WELL DRILLING LICENSE NUMBER -.--------.--ExPIRATION DATE_ <br /> PERFORATION CONTRACTOR______ —PHONE <br /> PERFORATION CONTRACTOR ADDRESS CITY/STATE/ZIP <br /> C"­C-5714ell Dniling License Number Expiration Date <br /> [:i Bureau of Aicohol, Tobacco and Firearms-Users of High Explosives License Number Expiration Date <br /> • CHIP mazarcous Mateniqi Transportation for Explosives :-icense Number ....... Expiration Date <br /> • San Joaquin County Sheriff-Cor-nne,Explosives Application and Perm:t License Number ......— Expiration Date <br /> 0 California Occupational Safety Heaith-Blaster License Number Expiration Date <br /> REASON FOR DESTRUCTION Q-�Ily 0 Replacernert Well [I Caved in El Pit'i'Vell �7 Inactive 7- Test Haie <br /> Dezened,S,jspecter.,Well Water Contaminant(s)___ <br /> Adjacent property with contamination(Address)____,__, <br /> Known So-i',Aate,contaminants at,---�Ijacent property <br /> EXISTING WELL CONSTRUCTION DETAILS 4?"Open Bottom 0 Gravel Pack 0 Uncased 71 0rher <br /> it Nell Log :,opy attached 01 'ves U-11c, Grout Seal 0 No 0 Yes ft below ground surface rs, Hole Diameter inches <br /> Ne Conductor Casing :] Yes 0 No Depth of Conductor Casing ft.bgs Diameter of Conductor Casing inches <br /> We��Casing Diameter V inchec, Total Depth ft Depth to Water -7 '1 Depth of Casing f"bgs <br /> DESTRUCTION SPECIFICATION <br /> Sealing Material I L. 'i t)os to ft bgs Filler Material <br /> Well casing to be perforated by one of the following methods: from if bgs to Dgs <br /> Mills Knife -Number of cuts every ft anoicir <br /> Explosives 0 Detonating cord 0 with projectiles every ft 0 without projectile <br /> :3 Detonating cord and boosters 0 with projectiles every ft 0 Without projectile <br /> Other <br /> Sealin-4-Material Neat Cement94 b bagl5-6 gal water) Sand Cement sack mix!/gal water Bentonite Pellets <br /> , <br /> ---Bentonite(2001.solids) Manufacturer Spec,1,6 solids % Name Specs or, F-ie Specs Submitted <br /> Placement Method Pumped Free Fall Cimer <br /> Seal Completion i� Mushroom Cap <br /> ft figs Ccr­;;iete to Existing Surface Pad <br /> 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 /> ..URRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> AORKERS COMPENSATION LAWS. <br /> MiNtMUN 24 HOUR ADVANCE NOTICE REQUIRED FOR 1,1SPECTIONS <br /> CONTRACTORS SIGNATURE —TITLE DATE <br /> f <br /> X <br /> P R U1 iT E <br /> 1-armit may have U,','Pired Without <br /> work being completed or insoecteo <br /> by Fnvironme;-Ital Health Divkjn <br /> SAN <br /> J0A0(,1IN <br /> CCIUNT�- <br /> 4- l"IrAl. <br /> N I" <br /> DEPARTMENT USE 0 N L Y <br /> 400tication Accepted Bv 'r Date I -3 Area <br /> ' <br /> -P <br /> Destruction inspection By Date Employee ID# ;qd_71?1k4LZ1,tW41- <br /> I <br /> C()MMENTSi i ��t"E-t -1 <br />