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rpv V-01 vVell UIIIIII1IJ uwuoc,vm uum ��yo/+y �nyu auvva.o <br /> ❑ -Sureau of Alcohol,Tobacco and Fire a Users of High Explosives License Number Expiration Date <br /> ❑ CHP Hazardous Material Transportati 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_ft below ground surface(bgs) Hole Diameter inches (1� <br /> Well Conductor Casing ❑ Yes ❑ No Depth of Conductor Casing ft bgs Diameter of Conductor Casing inches w <br /> Well Casing Diameter inches Total Depth ft Depth to Water ftyy11 Depth of Casing ft bgs <br /> DESTRUCTION SPECIFICATION �7T al <br /> Sealing Material from it bgs to ft bgs Filler Material amp'u m from ft bgs to It bgs <br /> Well casing to be perforated by one of the following methods: from ft bgs to ft bgs <br /> Mills Knife _ _Number of cuts every_ _ft and/or <br /> Explosives ❑ Detorlrating cord ❑ with projectiles everyIt ❑ without projectile <br /> ❑ Detonating cord and boosters ❑ with projectiles everyIt ❑ without projectile <br /> ❑ Other <br /> Sealing Material LiNeat Cement(94 lb bag/5-6 gal water)LlSand Cement `#r 3 sack mix/7 gal water ❑ Bentonite Pellets <br /> ❑ Bentonite(20%solids) ❑ Manufacturer Spec`Yo solids _% Name ❑ Specs on File ❑ Specs Submitted <br /> Placement Method ❑ Pumped ❑ Free Fall Other; `/I�Lf-( /D!y/lP <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 /> Mi G/y%C 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br /> CONTRACTORS SIGNATURE TITLE ATE <br /> -ems T2p <br /> �I <br /> S wrD tAYME <br /> Mrd RFCE'W6 <br /> Gam- APR 10 2009 <br /> &%J04 <br /> Ery QUIN <br /> HEACTN R�P � TY <br /> I <br /> DEPARTMENT USE O ::Nl!L 2////r/// <br /> Application4-Accepted By Date 2iVO Area JI —cT <br /> Destruction Inspection By Date > Employee ID#_cs q <br /> COMMENTS <br /> PE SC Received Amount Date Perin-it/Date WeIi ID# <br /> Codes Info B Cash Remitted Service Re uest# <br /> !f3? t6s 3 .250.00 ,2J D <br /> EHD 43-08 WELL DESTRUCTION PERMIT <br /> 10/5/07 <br />