Laserfiche WebLink
WELL DESTRUCTION PERMIT <br /> PUBLIC WATER SYSTEM}yyes ON" <br /> SAN JOAQVtN COUNTY ENVIRONMENTAL HEALTH DEPARrM®rr 600 E MAIN STREET_STOCKTON CA 95202 -(209)468-.U20 <br /> NON-REFUNDABLE PERMIT X-5/9 CALL 209 953-7597 FOR INSP e:.,.: EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS r4G r`hi- (-.tet �r.-.;• QtYlLP ,✓ %:/,� _ r �•-� .+� <br /> CROSS STREEET—:(i�AOIt/ �Y. G _IPN Zr9 (7�n -0t, r PAli SIM LAND USE APPLICATION <br /> owNER > i2TTI- / Pt1oNe ry!- .1 `' !• l"7 I <br /> OWNER ADD / ��• / CRYMTATP.(ZIP�l1`: C✓1 A <br /> CONTRACTOR''/4/"?:,- .A./in yl ?r 4.1z ,/1,44 PHONE 7 t r--(.c.c rl •�,� <br /> CONTRACTOR ADDREW ": +�!I d v,I / CUWSTATEMP .moi•%St i:2 07, �l! <br /> C-57 WEu_DmLLiw Lwast NW166R 71l f>'� E%PiRATION DATE <br /> PERFORATION CONTRACTOR '•/. - :'r!I 7PI 2/d / mme- "r''r 0 !flfs '�`II i- <br /> PERFO"COWRACTMADDRESB„ ,�TI I./.�,�, Y7j/'!A/ ��r CRY/STA"a-P �7�/.'• �!(� } <br /> d c37 Wo Doing License Number 7-S'!/3 3 ,,rEEx`piration Date <br /> Bureau of W".Tobacco and Forearms-Users of High Explosives License Number'/44067532 A IL/�arpiraeon Date d- <br /> CHP Hazardous Material Transportation W Explosives [.,,Arse Numbar Expiration Date / t <br /> a <br /> San JtNr9wn County Shona-Coroner Explosives Application and Permit Ucenae Plumber !'��-'U Expiration Date_.. <br /> Caltfomi,e Oxupationat Safety Viw tth-blaster License Number__!11!2L_ Expiration Date 1l/Z, <br /> RymgN FOR Dt'sEJRucT gm ❑ Dry ❑ Replacemegi Well ❑ Caved In ❑ Pit Wel • Inactive ❑ Test Hole <br /> Detected lSuspected Well Water Contaminargs) A,'",Adjacent prop"with Contamination(Address)_ <br /> Known Soil I Water corlbmMants al adjacent Property--- <br /> -a, <br /> roperty __ <br /> f:xigreiG lNELL C LTRUCitON DEfAllr} Open Bottom O Grovel Peds ❑ Unvimed ❑ Other s I <br /> Weil tag copy attached ❑ Yee '�No Grout Seal ❑ Ivo O Yes _ ,R helow ground surface(bgs) HON Dlarmter vrdies .I <br /> Wen Conductor Casing❑ Yes •❑ No Depth of ConductorC*inV y-___ -R Lys Diameter o(Conductor Casing inches <br /> wim Casing Dismster_-. t-, _enchm Tota)DeptW2__� . R Depa to Wabr it Depth of Caslnp" %! II Ma <br /> DeSTRCC7100 ST�CirtCAttON / <br /> Sealing Material from it bye to `'._. it bge Fi1Nr IlIxtertat h: _-.;�.__. .�.. \.�._ it Ags to, a.__11 bge 1 <br /> wan casing to be 2arforists by gm of the tel losvttta methods[ _ ----__-bom_C;7 bgs to _ t,Z__A bB! <br /> 0 ,Mlils Knft _ Number of cuts every____- _N and l m <br /> Cy Explosives❑ Detonating cord 177 with prajecilies every - - R ❑ Without pt*c(de <br /> O/Delonating cord and boosters with projectiles every 10, R �T without pie)ecele <br /> ❑ other. _ - - -- <br /> _ -_- -- -- -- I <br /> Sealing Material — 94 Ib bag/5-$gel water Sand Cemeatt S_srick mlr1 7 gal tater Bentonite Pellets <br /> F3eMOnite j2o°H sorids) Manufacturer Spec%sotds_% Nene_- __ Speca on File Specs Submitted <br /> Placement MsthodrP_umped_} Free Feil Other__ _ _ _ _ - <br /> Seal COMPlotton Complete wTl Mushroom Cap­ _-�R bgs CompWit,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 fi <br /> JOAQUIN COUNTY ORDINANCES, STATE. LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS E <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWr <br /> //QtEitatirt�{�' 3ei ANCE 'ICE REQUIRED FORINLkPECTiONS ' <br /> cacTRACTatsSwHn �`^ `�}} DATE <br /> Re EHEC <br /> w. <br /> lol� MOt <br /> Hr1't' <br /> OEPARTtklFNT USEON Y G <br /> Application Accept 3 Al AM-- — <br /> Destruclion I - By _ Dan °°WX ��lS <br /> Ct.MAMENrS - <br /> PE 8C I ReCellied Antgplt 'Pertnitl <br /> Codes pdp DNrr Service Request N D I <br /> y373 �. 7l8S� P� 3 -D t �, <br /> may(,�,�,� <br /> EHD4308 i?/�O ate.�ft�� Ui0"yam"`DF. <br /> 004182 T <br />