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Vrc�i DESTRUCTION PERMIT <br /> PUBLICWATFRVV11M t Yes 0 No <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 E MAIN STREE7-STOCKTON CA 95202- (209)B68.34Z0 <br /> NON-RF.VUNDABI-i✓PERMIT CALL 209 963-769-1 FOR INSPECTIONS EXPIRE$1 YEAR FROM DATE ISSUED l <br /> 938 Frontage Rd. CmfzjP P.3 on CA 95365 q <br /> JOB ADDREst <br /> GRosa STREET 8 rady Tin. APN 21 <br /> 1-0 3 C-0 7 PARCEL SEE 1__'�L7AN0 Use Al-t•uCATION# <br /> RF Land, znc. PHONE (209)X76-8213 <br /> OWNER CHQNt7ATE�ZJP $toCktorj, Cn 95219 <br /> pWNERADDRE85 37 D5 portsmouth Circle tvorch aHQ�C686 <br /> IncPHONE (916 <br /> CONTRACTOaLer Well Technole <br /> . <br /> cITY15TATF_17JF �'Gir Oaks CA 9 562 8 � <br /> CONTRACTOR ADDRESS P- - X XpIRATtON DATE 1-• 3 1 11 <br /> C-57 WEI-L DRILLING LICUMSE NUMBER, T� 2 <br /> Same PNONic <br /> FERFORATIQN CONTRACTOR. ........................ <br /> ,�,.CITYJSTATEOP <br /> PERFORATION CONTRACTOR AvvaESS <br /> 'ration Dae 3 11 <br /> LlcenseNuml;?er 73513 Exp += <br /> I C-57 Well Drilling5Cpns7399A7.213[i Expiration Date Current <br /> Bureau of Alcohol.Tobacco and Firearms-Uaerc of�4h=xplosives Llcense Number 13 7 Llc_nse Numbflr 17 FxpiraUon flats ''rte 9 <br /> 4 <br /> CHPHazardousMaterialTransportationfirF�,'PI00ves 0804 Expiration0ste x/9'159 <br /> San Joaquin County Sheliff Coroner jYxpiosives Application and Pemllt Licensa Number +r Exptration Date 1/411 t2 114 <br /> License Number (� <br /> Calitomla Ocz pagonsi Safety H=aAh-Blaciarinactive O Test Hole <br /> REABO R DUST D Dry ❑ Replacement WAIT ❑ Caved In !❑ �V�V'� <br /> Detected/Suspected Well Water Contatnlnant(n) 1 Oy <br /> Adjacentproperty with contamination(Address) rTi tYat� — � <br /> Known Solt I Water coniamirrant$at adjaoent property <br /> gn Bottom 0� Gravel Pacr Q UnCtWd ❑ Other 12 Inches <br /> E lI,71wG V11ELLCONSTRU IR_SsLa 2E AJ1. ❑ OP [: Yes g G ft below ground surface(bgs) Hole Dlameter - <br /> Well Log copy attached I Yes Q No Grout Seal J No ft bgs Dlamelor cf Conductor Casing inches <br /> Wo11 Conductor Casing CI Yes l No Depth of conductor Casing <br /> Woll Casing Dlamater 8-5/8 <br /> orches Total Depth 2 0 0 h Depth to Water `-1 ft Depth of Casing 19 b ft b9Z <br /> Dr'S'rlinCTl0MSr Krg)n-ATION b s t0 (t bps <br /> Sealing Material from 0 g bas to 196 ft bgs Filler Material) W s m � k bgsto_91�-S_n b9g <br /> Well casing to tIe rt to by ne of th folio macho <br /> 0 or <br /> Millis Knife __Number Of cuts every ft art /v <br /> Q with projectiles every���ft <br /> ft Q without projectile <br /> Explosives Detonating mrd p without projettlle <br /> Detonating cord and boosters C with projectiles every <br /> )( <br /> = Otho 10.3 sack mix 17 gal wobar Bentonite Pellets <br /> Sealing Material Neat Gement{841b bag 5 s Spf water) Sand Cement — Bpeas on File Specs Submitted <br /> Hantonite(20%509ds) Manuf°cturcr Spea°ro solids °° Name Omar <br /> Placement Method Pumped Free Fall <br /> Seal Completion Complete with Mushroom Gap,�—•—R logs <br /> Complete to Existing Suruct Pad <br /> 1 HSltII9Y CERTIFY THAT I HAVE PREpaRED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WIT" SAN <br /> JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS, I ALSO CERTIFY THAT MY REQUIRE'] LICENSE IS <br /> CURRENT AND ACTIVE WtTH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT 1 AM IN COMPLIANCE AITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> MINIMUM 24 HOU"0VA 5 NOTICE REQUIRED FOR INSPECTIONS f <br /> 1 TITLE <br /> CONYRACTORS SIGNATURE ; <br /> -- <br /> �TMACX <br /> I <br /> I —ter.. __" - _ -- _...,.__... — -_ ...1.,....-i_—'_... _. —1•^---- I . <br /> I <br /> — _ - — ' <br /> - <br /> _s <br /> T. <br /> I 1 � <br /> J.� DEFARTMENT 'ISE ONLY / <br /> Date � <br /> App:'IcativnAacePtnd r 7r�Zl/�� 3 <br /> Date AeA 0 cmpioyee IGii <br /> Destruction Inspectlan BY - r ' <br />