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GVELL DESTRUCTION PERM <br /> PUBLIC WATER SYSTEM []Yes kNo <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Y 600 E MAIN STREET-STOCKTON CA 95202 - (209)4683420 <br /> NON-REFUNDABLE PERMIT CALL(2091953-7697 FOR SPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS CITY/ZIP �)�/�t <br /> CROSS STREET <br /> J� e f /,�t-r/V-�1�--,/)A—�PN (�O � PARCEL S_I_ZEE /43Q LAND USE APPLICCAATION# o <br /> OWNER C7/�L y f� 1 /y!-/C' '(�/�� 1C. PHONE/ 7%7-��}117Z^7Z� Qom/ <br /> OWNER ADDRESS / .FZ ITY/STATE/ZZII'PP --k \ca <br /> CONTRACTOR Dig PHONE_(5,��/r2/�— <br /> CONTRACTOR ADDRESS J CITY/STATE/ZIP 5/r�"'I/ <br /> QY� C$7 WELL DRILLING LICENSE NUMBER �Oa,,�/ (� EXPIRATION DATEff4D� Q <br /> PERRF_ORATION CONTRACTOR (i1i1�'17�? / L/ �/�I PHONE <br /> PERFORATION CONTRACTOR ADDRESS JG(l! ✓✓LV� ��N/STATE21P <br /> >ID I C-57 Well Drilling License Number y� �-� 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 /> ❑ 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 active ❑ Test Hole <br /> Detected/Suspected Well Water Contaminant(s) <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 ❑ Yes ❑ No Grout Seal ❑ No ❑ Yes _It below ground surface(bgs) Hole Diameter inches <br /> Well Conductor Casing ❑ Yes ❑ No Depth of Conductor Casing It bgs Diameter of Conductor Casing inches W <br /> Well Casing Diameter inches Total Depth ft Depth to Water ft Depth of Casing ft bgs <br /> DESTRUCTION SPECIFICATION n <br /> Sealing Material from ft bgs to ft bgs Filler Material Bd �Gu 7 ��D� p from It bgs to ft bgs <br /> Well casing to be Perforate d by one of the following methods: from ft bgs to ft bgs <br /> Mills Knife _ _Number of cuts every _ft and/or <br /> Explosives ❑ Detonating cord ❑ with projectiles everyft ❑ without projectile <br /> ❑ Detonating cord and boosters ❑ with projectiles everyft ❑ Without projectile <br /> ❑ Other ' <br /> Sealing Material ❑ Neat Cement(94/b bag/5-6 gal water)❑ Sand Cement `sack mix/7 gal water ❑ Bentonite Pellets <br /> ❑ Bentonite(20%solids) ❑ Manufacturer Spec%solids _% Name ❑ Specs on File ❑ Specs Submitted <br /> Placement Method ❑ Pumped ❑ Free Fall >0 Other�'1T/7 <br /> Seal Completion Complete with Mushroom Cap 3 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 /> M/IJNI JM//UJJyU��, 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br /> CONTRACTORS SIGNATURE // i�'/K /i�l \ TITLE ATE <br /> �FCE ANT <br /> t1�\� snn,JG 1 ?009 <br /> "AIYJ��FY�i hFjl�Ep gCMA(Nry <br />