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WELL DESTRUCTION PERMIT SCANNED <br /> -lnO/t—) PUBLIC WATER$YSTEM []Yrs QNo <br /> teal/ L 5N <br /> i <br /> SAN JOnQU1NCOU�'it'ENVIRONMENTAL HEALTH DEPARTMENT 304 F.WEtlEuAVE3Y°FLOOR-S TO 95202 - (209)468-3420 <br /> NON-REFUNDABLE PER �S CAI.I,(2U9 953-7697 FOR INSPECTIONS �1o�Atk� 'E R ROM DATE.ISSUED <br /> JOB ADDRE a7 C]TY/ZIP I <br /> 01.7,.RG U C PHONE. — IM q <br /> c <br /> _ O <br /> OWNER AD SS +.2 CITY/STATEJZIP <br /> C4 <br /> m <br /> CONTRACTO t PHONE <br /> I t741- 2- <br /> i <br /> lCONTRACTOR AUURESS ckocs. kilJ CITYISTATE/ZIP <br /> 1-57 WELL.DRILLING LICENSE•NUMBER F/ EXPIRATION DATE <br /> PERFORATION'COVTRACTOR PHONE <br /> PERFORATION CONTRACTOR ADDRESS CITY/STATFIZIP <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 Tramponation for Explosives License Number Expiration Nate <br /> ❑ San Joaquin County Sheriff-Coroner Explosives Application and Permit License Number Expiration Date <br /> ❑ California Occupational Safety Health-Blaster License Number Expiration Date <br /> REASON FOR DESTRUCTION ❑ Dry ❑ Replacement Well ❑ Caved In ❑ Pit Well ❑ Inactive ❑ Test Hole rv(� <br /> Detected I Suspected Well Water Contaminant(%): _ V <br /> Adjacent property with contamination(Address): <br /> Known Soil/Water contaminants at adjacent property: <br /> I <br /> EXI.STIVC WELLCONSPRIJ TIONDFTAIISS 0 Open Bottom Gravel Pack CIUncascd ❑ Other ' <br /> Well Log copy attached EIes Yes No Grout Se■1 ❑ No .❑ Yes R below ground stuface(bgs) Hole Diameter inches. <br /> Well Conductor Casing [IYes 1Y-gDepth of Conductor Casing R bgs Diameter of Conductor Casing inches <br /> Well Casing Diameter _inches Total Depth(//II�Or R Depth to Water R Depth of Casing R bgs <br /> DESTRUCTION SPECIFICA !: <br /> Sealing Materlal from A bgs to i R bgs Filler Material frorr iZ�s toeaW _R bgs <br /> Well casing to be perforated by one of the following methods from R bgs to R bgs <br /> ❑ Mills Knife Number of cuts everyR and/or 1Z, <br /> J` <br /> ❑ Explosives ❑ Detonating cord: ❑ with projectiles every tt ❑ without projectile L <br /> ❑ Detonating cord and boosters: ❑ with projectiles everytl ❑ without pmjcctilc <br /> ❑ Other_ _ <br /> Seall aterial ❑ Neat Cement(94 lb bag IJ-6 gal water) Sand Cement��ruck mir/7 g``al water ❑ Bentonite Pellets <br /> m <br /> entonite(20%solid El Manufacturer Spec%sohds ly% Nameny •• Pecs on File ❑ Specs Submitted <br /> Placeent Me[hnd L7 Pu�Iped ❑ Free Fall ❑ Other <br /> Seal Completion: <br /> Complete with Mushroom Cap ft bgs ❑ Complete to Existing 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 REGLLATIONS. 1 ALSO CERTIFY THAT MY REQUIRED LICENSE I' <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT 1 AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAW'S. <br /> ' I <br /> MIN 4 UR D ANCE NOTICE REQUIRED FO NSPECTIONS <br /> r- <br /> CONTRACTORS SIGNATURE: TITL DATE: <br /> AJ <br /> I At <br /> IF <br /> Ali <br /> 1-Y <br /> �- _ _- _.moi-..—�---.r.» --•�- -- ---- �.�. .,.r=..�+....r:�..�-�----- --4 - _.�._ _ .�-.l <br /> DEPARTMENT ONLY �V <br /> APP caon Accepted By Dace Arca <br /> Destruction Inspection By A llace _ = -�{ � "is Employee ID# <br /> COMMENTS <br /> PE SC Received hec Amount D to PermiU Invoice# Well ID# <br /> Codes info v ash Remitted Service Request# <br /> o�u3Z _ ii <br /> w,.n ti�vrme Permit Ada<naum tops t r-a� .. <br />