Laserfiche WebLink
WELL DESTRUCTION PERMIT SCANNED <br /> i I G• �''Q��°5 f��//�►�) Zoll—do <br /> Z/R PUBLIC WATER SYSTEM O Yo❑No <br /> 1 SAN JOAQQUIN COU`TY ENVIRONMENTAL HEALTH DEPARTMENT r n•- V f 304 E WEet.R AVE 3"'FLOOR-sT(oy��cT 95202 - (209)468-3420 <br /> NON-REFUNDABLE PERK S CALL(209 953-7697 FOR INSPECTIONS O�FIR�S I E A ROnf DATE ISSUED <br /> JOB ADORE 7 Crrvrh I <br /> OWNER N - ii" C PHONE. <br /> �) <br /> OWNER An �V ClrrlSrArtlLrOf7 P <br /> (Nvi <br /> CONTRACTO 1/ PHONE <br /> 64 <br /> CONTRACTORADDRESS CITY/STATEl7JP + <br /> C-97 WELT.DRILLING LICENSE NUMBER I EXPIRATION DA <br /> PERFORATION CONTRACTOR PHONE <br /> I PERFORATION CONTRACTOR ADDRF-m CITY/STATErLtl <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 Hamrdous Material Transportation for Explosives license Number Expiratinn Date +' <br /> ❑ San kAquin Ctwnty SheriffCoroner Explosives Application and PemoL License Number Expiration Date <br /> ' ❑ California Occupational Safety Health-Blaster License Number Expiration Chu <br /> REASON FOR DESTRUCTION ❑ Dry ❑ Replacement Well ❑ Caved In ❑ Pit Well Cl Inactive ❑ Test Hole <br /> ' Detected/Suspected Well Water Cents minent(s): _ Vr <br /> i <br /> Adjacent property with contamination (Address): <br /> Known Soil/Water contaminants at adjacent property: ' <br /> EXISTING WELL CONSTRUCTION DETAILS❑ Open Bottom Gravel Pack ❑ Uncased ❑ Other ' <br /> Well Log copy attached C1 Yes Ngo Grout Seal 11 No .11 Yes R below ground stuface(bgs) HoleDiameter inches <br /> Yes . <br /> Well Conductor Casing ❑ YL)- o Depth of Conductor Casing ft bgs Diameter of Conductor Casing inches <br /> Well Caring Dlatneter__inches Total Depth [Q�/ft Depth to Water ft Depth of Casint - R logs <br /> DESTRUCTION SPEC]FICA <br /> Sealing Material fromA bgs to-4-4�p ft bgs Filler Material •�� fro to�;�_R bgs <br /> Well easing to be perforated by one of the following methods from ft bgs to _ft bgs <br /> ❑ MIB Knife Number of cuts everyft and/or <br /> ❑ Explosives ❑ Detonating cord: ❑ with projectiles every tl ❑ without projectile I <br /> ❑ Detonating cord and boosters: ❑ with projectileseveryiI - - ❑ without projectile <br /> O Other _ <br /> Seslln sterial ❑ Neat Cement(94/b bag 13-6 gR!an(rr) =-S--d Cement ly A inirJJW <br /> 7 gawata ❑ Beatonite Pellets <br /> ntosite(20%is 13Manu&eturtx Spec%solids % Nam +YyEgo., pas on Fife ❑ Spm SubmitteC <br /> Placement Method ❑ 1't3yped ❑ Free Fall 13 Other <br /> Seal Completion: G/Complete with Mushroom Cap R bgs ❑ Complete to Exit ing Surface Pad t <br /> 1 HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH S <br /> JOAQUIN COUNTY ORDINANCES, STATE LAWS,AND RULES AND REGULATIONS. 1 ALSO CERTIFY THAT-MY REQUIRED LICENSE I <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT i AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> ' a <br /> MIN 4 LLhUR D ANCE NOTICE REQUIRED FO NSPECTIONS <br /> r <br /> CONTRACTORS SIGNATURE: TIT L DATE: <br /> I <br /> I— - <br /> I ou- <br /> _ l <br /> DEPARTMENT ONLY <br /> 2 J ni nUCJ <br /> Application Accepted By / Date A 6 <br /> .7 C' _ -- <br /> Destruction Inspection By (. A ^ Uatc _ /^ --.�Uii3s :1 Employ=ID# <br /> COMMENTS 1 <br /> i <br /> PE SC Received Amount D to Permit/ fRrtdoe/ Ws11IDM <br /> Codes into v Reruitted Service cent# r I <br /> / <br /> EHD U-03Jax _ uA.n rc-....�:.-ate.ata....' A..0�.•...... <br />