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F WELL 1�5TRUCTION PERMIT ADDS, <br /> n <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> OCT T % 5 2006 <br /> 304 E WEBER AVE 3-FLOOR-STOCKTON CA 952 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953_697.f'OIt EXPIRES 1 Y <br /> Le <br /> JOB ADDRESS Ripona Market at 223 W. Washington Street CITY/ZIP Ripon / 95MMIT/MFMCES <br /> CONTRACTOR V&W Drilling / M.J. Kloberdanz & Associates PHONE 916-777-4100 / 209-S77-8186 �d <br /> CONTRACTOR ADDRESS M.J. Kloberdanz & Associates, P.O. Box 576981CITY/STATE/ZIP Modesto, CA 95357 <br /> 3 <br /> I <br /> 1 <br /> WELL WATER WITH ` <br /> CONTAMINANTS. f <br /> ADJACENT PROPERTY AT <br /> WITH SOILAWATER CONTAINING <br /> CONTAMINANTS OF <br /> j <br /> I <br /> WELL LOG COPY ATTACHED ❑ Yes IZXNo Logs On file a DEFT DIAMETER OF CONDUCTOR CASING 14W-4) 8 5/$ inches iF <br /> WELL WITH CONDUCTOR CASING ❑ Yes [9X No DEPTH OF CONDUCTOR CASING ft bgs <br /> LICENSE <br /> ®XC-57Well Drilling License Number C-57-720904 Expiration Date 4-30-07 <br /> ❑ Bureau of Alcohol,Tobacco and Firearms-Users of High Explosives License Number Expiration Date <br /> ❑ CHP Hazardous Material Transportation for Explosives License Number Expiration Date <br /> ❑ San Joaquin County Sheriff Coroner Explosives Application and Permit License Number € <br /> Expiration Date <br /> ❑ California Occupational Safety Health-Blaster License Number Expiration Date <br /> WELL DESTRUCTION ❑Open Bottom ❑Gravel Pack ❑Uncased XXOther Monitoring Wells <br /> Well Diameter 2 in Total Depth 35,50,6 0 ft Depth to Water -25 ft ❑Casing to be Perforated from ft to f} <br /> Seating Material Meat Cement(941b bag 15-10 gal wader) ❑Sand Cement sack mix l7 gal water ❑Bentonite Pellets <br /> ❑Bentonite(20%solids) ❑Manufacturer Spec%solids % Name ❑Specs on File ❑Specs Submitted <br /> Placement Method ZRPumped ❑Free Fall ❑Other <br /> Complete with Mushroom Cap 3 ft below grade ❑Complete to Existing Surface Pad <br /> METHOD OF WELL CASING PERFORATION NA <br /> Well casing to be perforated from ft bgs to <br /> It bgs <br /> ❑ Mills Knife Number of cuts every ft and/or <br /> ❑ Explosives ❑ Detonating cord only with or without projectiles every ft <br /> I <br /> ❑ Detonating cord and boosters with or without projectiles every ft E U, <br /> ❑ Other 3' <br /> ❑ Other <br /> I HEREBY CERTIFY THAT I HAVE THE AUTHORITY TO COMMIT THE ACTIVITY DESCRIBED ABOVE FOR THIS CONTRACTOR,THAT I HAVE <br /> PREPARED THIS APPLICATION AND THAT THE WORK WIL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE <br /> LAWS, RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS CURRENT AND ACTIVE WITH THE CALIFORNIA <br /> CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION LAWS. <br /> 1INIM1JN] 24 HOLM ADVANCE NOTICE REQI.11RE'D FOR INSPEIC T10NS ` <br /> SIGNED TITLE e-t.`ti�( ti�- DATE L <br /> DEPARTMENT USE ONLY ``�� p <br /> Application Accepted By n <br /> t - Date O Vo Area (y 2-f I <br /> Destruction Inspection By Date <br /> Datc. 106 Employee ID# <br /> COMMENTS <br /> wusl Li <br /> PE SC Received Check#/ Amount Permit/ <br /> Codes Info By Cash Remitted Date Service Request 4 Invoice# Well ID# <br /> ;T*Z 60 <br /> W <br /> V20W02-008 <br /> 3lh004 w <br /> Well Desctim Pernul Addendumdm <br /> WV20W <br />