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WELN...,CSTRUCTION PERMIT ` / PUBLIC WATERSYSTEM [IYes Jl(J NO T SAN JOAQUIN COUNY ENVIRONMENTAL I1EAL'1'11 DEPAR I'MFNT 304 L WEBER AVE3°p FL-S'1'OCK'I'ON CA 95202 - (2099)4``68-3420 q:opy NON-REFUNDABLE PERMIT CALL 2`1119 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED JOR ADDI<ESS rr/��Zrr��O 3/ N V/,L5C1/V �R 7 CI'rY,ZIP S'Tc'a C K1'o�/r C�1 93z 0.� FILE C cROss STREET T`D-d 'PRLZ AVE, APN f17-0-7-10 PARCELSIZE LAND USE APPLICATION# Orvlvrat /V�-�../�/�/1tiL �T�[ PIIONEC-ZOq)`f 6'� —_9_� OxVNI:R AUm ,,Ss �.' q 3 L-J'V--1 ( �_ CI1Y/S'I'A1 E/Zll• �'♦C.cIRO/Vi CONTRACTOR W,,+"kKyykt-L TFO,y/yOc-06Y� Ir/c• rRONECl(f q61 —93.55 CONTRACTOR ADDRESS I�' �• Q('X J (q CITY/STATE/ZIP YFA)tZ OAKS C4 ctS6R9 ' K-C-57 WELL DRILLING LICENSE NUMBER 73 f f -3 E%PIRATION DA'rF'X, I( 3I rO-7 PERF'ORA'i'WN CONTItACI'OlY<VV f�I EK VVF-L^^L- I EL?f/ ZA>C4 !N C PHONE)( PLLR-FORATION CONTRACTOR ADDRESS;" CITY/STATE/ZIP"" 1 �� C-57 Well Drilling License Number 3 1(33 Expiratiot ate 3( 07 Bureau of Alcohol,Tobacco and Firearms-Users of high Explosives License Nmnber4,'AO(a7336J11R13L5xpirati I Date ( ( Df. CHP Hazardous Material Transportation for fix losiv• j ,..t P P lS��' License Number /3�Fg1( +tm Expiration Date ?31 as0� 2k San Joaquin County Shcriff-Curoncr Explosives Application and Period License Number O�f•-'(;Z Expiration Date K . 1) California Occupational Safety Health-Blaster License Number $46 Expiration Date (rZ .Z( 0 REASON EOR DESTRUCTION ❑ Dry ❑ Replaccutent Well / ❑ Caved In ❑ Pit Well bmctive ❑ Test hole Detected/Suspected Well Water Contamivant(s) f 2- DC,j ( X0.5 3.0 \J Adjacent property with contamination(Address)�6g . W t 1. o W^Y OR�7c>f -/V, Vy 1 2-,SON —Aly Known Soil/Willer contaminants at adjacent properly 1-2?f 6 g lex 1&%-r3t, 1,:z-1P.C.4 1'.SISI'INC WI':LI.CONS'1'ItUCTIUN DFPt'AIL ❑ Open Don-Ill ❑ Gravel Pack ❑ Uucuscd Other U/V f�1/OW/✓ Well Lug copy attached ❑ Yes Nu Grout Seal ❑ No ❑ Yes It below ground surface(bgs) Hole Diumeter inches \Yell Couduclur Casing ❑ Yes ❑ No Depll.of Cand clur Casing n bgs Diameter of Cut doctor Casing inches Well Casing Diamelet'�_-_inches Tutu.Depth{ 7W R Deptb to Wnter-v GO It Depth Of Casing"'('-1.� R bgs DI'WRUCTION SPECIFICATION Sealing Material from R bgs tol 5O R bgs Filler Material from It bgs to R bgs Well casing to be Derforated by uoc of the followine nlelbuds• front /5 R bgs to 4-rD R bgs ❑ Mills Knife Numbcr of cuts every It and/or 'VCExplosives ❑ Detonating cord ❑ with projectiles every ft ❑ Withoutprojectile 11 Other ' Detonating cord and boosters ,$T with projectiles every R without projectile (ice Sealing Materiul ❑ Ncat Cemcnt(Y4(b bug l S-6 ga!Ovate,) Sand Cement /O mix, gal watt, ❑ Isenlmlite Pellets ❑ Bentonite(20%solids) ❑ Manufacturer Spec%solids_% Nance ❑ Specs on File ❑ Specs Submitted Placement MetPumped ❑ Free Fall ❑ Other Seal Cungdcl.uu Complete with Mushroom Cap 3 It bgs ❑ Complete to Exis(iug Surface l'nd 1 HEREDY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JUAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. 1 ALSO CERTIFY THAT MY REQUIRED LICENSE IS CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT 1 AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION LAWS. MININIUN1 24 HO"ADS A�/�1'�N�O•fICE REQUIRED FOR E INSI' CI-IONS CONTRACTORS SIGNATURE / r C-n��6.zATLEAGJ5NrDATE ' r7l05 I -1 / I � O Ill N - � I w I I ZTM1IENT USE ON LY Application Accepted By Dale — Area _ Destruction Inspection By_ Date / V Employee I DII COMMENTS P L _ PE SC Received Checl,41 Amount Period/ Codes Info B ash Remitted Date Service It nest# Invoice# Well IDN C)lq a so.— 5-:;- h.eov 3