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09/25/2019 07:57 Canepa ur Sons (FAX) P.002/008 WELL DESTRUCTION PERMIT PUBLIC WAVER SYSTEM Ely- ❑No SAN JOAOUIN COUNTY ENVIRONMENTAL HEALTH DEPT 1 B69 East Hazelton Avenue-STOCKTON CA 95206-6232 •(209)468.9420 NON.REFUNDABLE PERMIT CALL 209 953.7697 FOR INSPECTONS EXPIRES 1 YEAR FROM DATE ISSUED JoeAOOREss �,�759/7 .S TOS e CITYIZIP �yyN GA• �53fi GROSS STREETN' A/� CPN a/z/5-/�'O-O�D-a00 PARCEL St �.1d01)q8E APPUCATIDN ff .y OWNER �0/Irk,{//�N�/J /� ^ PHONE ;} ffi- �r 9 OWNERADDREGS/•/ �� 14 CITYISTATErZJP/�r' `•r' ,gw - CONTRAcroR_CANEPA AND SONS INC. PHONE (209)532-1136 CONTRACTOR ADDRESS 14384 CLMSTA COURT CnyISTATEIZIP SONOR V CA 95370 CS7WELLDRILLING LICBNNS/I�NNUMBER 425149 !� �� EXPIRATIO14DATyE -707/31/2020 PERFORATION CONTRACTO^ :p 1� c 6i nS )�y�LtA$ ,4e. PHONE 1 1 PERFORATION CONTRACTOR ADDRESS CrrY/$7ATEJTIP ❑ 047 Well Drilling License Number Expiration Date Bureau of Alcohol,Tobacco and Firearms-Users of High Explosives License Number r Expiration Date ilk CHP Hazardoue Materiel Transportation for Explosives License Number Expiration Date San Josquin County SherSfFCoroner Explosives Application and Permit Llcer a Number + expiratlon Date , California Oceupattonsl Safety Health-Blaster License Number Expiration Date REASON F DEsTR CUW q Dy Replacement Well ❑ Caved In ❑ Plt Well 0 Inactive 0 Tcst Hole Detected/Suspectcd Wall Wetar Contain 18n e) Adjacent property with contamination(Address) Known SnII/Water contaminants at adjacent Props rp (+ C/VEO Ex1snN WeLL CONaTRUCTON DBTPILa. d Open Bottom Gravel Peck ❑ Uncasod ❑ Other S�`p Well Log copy attached 0 Yes �No Grout Seal ❑ No ❑ Yes ft below ground suFaCe(bgs) Hole Dfemeter� =Inc"a4 JV Well Conductor Casing❑ Yes O No Depth of Conductor Casing It bpy Dlametcr of Conductor Caning IncP,es ,/DA 019 Well Casing Dletnetor Inches Total Depth H Depth tO Water [�� R Depth Of Caaing ft t CNV/&0Aj.-c� N ly DU1QkIrrtON�ccrT!CAT12N fN�FPARTT Sealing Material from A-4";:' ft bps to ft bg. Filler Material from R bgs to ft bgs MFNT Well casing to be oeRorated by one of the tollowin methods; from h bgs to ft bgs ❑ Mills Knife Numbcr of cuts every h and/or )(Explosives❑ Detonating cora O with projectiles every R O without projectile ,��'►�n'`�'�L7 Detonating cord end boosters ❑ w th projectiles eve y ft ❑ without projectile C3 oft Sealing Material Neat Cement(941p Dag/"gal wat04 Sand Cement V Back m1x 17 gal water Bentonite Pellets Bentonite(20%sollds) facturer Spec%Solids_% Name Space on File Specs Submitted Placement Method umped Free Faller� Other Seal Completion Complete vri Mushroom Cap a n Das Complcic to Existing SurPaco Pad I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE MWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION LAWS. IItdUM 46 HOUR ADVANCE NOTICE REQUIRED �^FOP INSPECTIONS CONTRACTORS 91GNATURE T1TL �/��/946V7' DATE 1 I I — -H= I _ T. PA TM ENT USE 0NLf ApplicationAccepted By Date Area Destruction Inspection By diS Dat J Employee I D11 COMMENTS IMCe.�. s Ct.rvK XTirre—,SeIP251�-20"169-- ce eCheckit/ Am unt Date Penniv Invoice R Well IDs B ash Rem tree SorviCeRe oast#Po 4oi a8CIt11�It0, 0? V 2 dEHD3•aa J A�Y� V 0. 1 0 � /112V2, "7 WELL DESTRUCTION PERMIT