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WELL DESTRUCTION PERMIT <br /> + - r PUBLIC WATER SYSTEM ❑ Yes Q4 No <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304E'WEHER AVE 3Pe PL -STOCKTON CA 95202 - (209) 468-3420 <br /> NON-REFUNDABLE PERMIT CALL (209) 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> Jo¢ ADDEEas 8855 UORTUXRAX THORNTON RD . CITY/ZIP STOCKTON 5 Q <br /> CROSS STREET WAGNER_ HEIGHTS RD , APN C)&& 3w —t5' PARCEL SIL¢a 6 LANDUSEAPPLICATION # e <br /> OWNER GENARO 'CARVAJAL1 - PHONE 477-9977 - Armando @ -S . E .A-_ <br /> OvINERAoDREss R. O . BOX 7441 cITY/srAiump STOCKTON . CA 95267 <br /> CONTRACTOR HENNINGS- BROS . . DRILLING CO . , INC . PHONE 545- 1185 - <br /> CONTRACroRADDRESS 3525 PELANDALE AVE _ • cITY/srAwzip MOf)FSTD, CA g57Ffi <br /> IX C-57WELLDMLLING LICMMNUMBER 290813 ExPIRAnoN/D�LTE�MAY <br /> 331 }2008 <br /> PERFORATION CONTRACTOR PHONE 3f/ <br /> PERFORATION CONTRACTOR ADDRPSS CITY/STATE/ZIP <br /> (X C-57 Well Dating License Number 290813 Expiration Date 5-3148 <br /> ❑ Bureau ofAlcobol, Tobaccoand Firearms - Users of High Explosives License Number - Expiration Date <br /> ❑ CHP Hazardous Material Transportation for Explosives License Number Expiration Date <br /> ❑ <br /> 'so <br /> ]oequin County Shcriff-Coroner Explosives Application and Permit License Number Expiration Date' <br /> ❑ Celffomia Occupational Safety Health - Blaster - License Number Expiration Date <br /> REASONFORDERTRUCrION ❑ Dry ❑ Replacement Well ❑ Caved to ❑ Pit Well W Inactive ❑ Test Hole <br /> ❑girded / Suspected Weil Water Contaminant(s) f]. <br /> Adjacent property with contamination (Address) _ODP <br /> Known Soil / Water contaminants at adjacent property rVJ1" <br /> EXIsrING WELT. GONSTx on DETAILS ❑ OperRottom ❑ Gravel Pack ❑ Unused IQ Other unknown <br /> Well Log copy attached ❑ Yes X7( No Grout Seal ❑ No ❑ Yes R below ground surface (bgs) Hole Diameter inches <br /> Well Conductor Casing ❑ Yes ❑ No Depth of Conduct sing-_it bgs Diameter of Conductor Casing inches <br /> L Well Casing Diameter 6 5 /8 " inches Total Depth it Depth 10 Water R Depth of Casing ft bin Q <br /> f <br /> DFSTROL-I,onsPECIF,CATION PUMP IS CURRENTLY IN WELL 2. <br /> Sealing Material from 0 R bgs to bottom it bgs Filler Material from fl bgs to B bgs <br /> Well casing to be perforated by one of the fallowing methods: from itbgs to - Rbgs <br /> ❑ Mills Knife Number of cuts every R and / or <br /> ❑ Explosives ❑ Detonating cord ❑ with p jectilesevery it ❑ without projectile <br /> ❑ Detonating cord and boosters ❑ with p jecdlesevery - B Elwithout projectiler\ <br /> ❑ Other <br /> Sealing Material ❑ Neat Cement (94 /AbRK/5-6gnl wnrcr) ❑ Sand Cement sack mixt ] gal weer ❑ Bentonite Pellets <br /> [X Bemonite (20% solids) ❑ Manufacturer Spec % solids . % . Name ❑ Specs on File , ❑ Specs Submitted <br /> Placement Method CX Pumped ❑ FrceFall ' - ❑ OtheI - <br /> Sea] Completion EX Complete with Mushroom Cap - -�Rbgs ❑ Completeto Existing Surface Pad <br /> ` 1 HEREBY CERTIFY THAT 1 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, 1 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 /> ---MIMAIAP -24 HD1jR-A V-ANGE `0T4C:; ANSPEETIONS--____. ._ - <br /> CoNraAcroSlcNATUR¢ s TLE SUP <br /> xsERVISO DATE 7-22-08 <br /> L —I LuesLr L <br /> 7 ' © -- <br /> PFF <br /> r�� _ <br /> r--(- yj 7—{� EHV/ROryINto <br /> '- ` r2j f (- . L . � x1�1LTH pE _ <br /> . . DEP A JLT-14£-FFT'--U-5-E— 3 <br /> Apphcabon Accepted By Date .2S- O Mea �G[ 7y <br /> Destruction Inspection By - Date .Employee ID0 sS 'PEkV <br /> COMMENTS JZ '/ LqI <br /> -6' �A/-l0e>7J �!//1f1�-�12'G✓L7l.iYJ/� <br /> PE SC Received Chec / Amount Permit/ <br /> Codes Info B Cas Remitted Dale Service Request # Invoice0 We111Dq <br /> Y37-3 t&1114q� $ 7I q !So 1 '� 6 9 6 - <br />