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WELL4"tSTRUCTION PERMIT FILE COPY PUBLIC WATER SYSTEM ❑Yes No 2, SAN Jl1AQUIN COUN'T'Y ENVIItONNIENTAL H EAL'I'li DEPAR MEN'l3111 EWt:wiit AVE 3°1i FL-S-I'OCK'I'ONCA95202 - (209)461�-3420 NON-REFUNDABLE PERMIT CALL 209 953-7697 ICOR INSPEC'T'IONS EXPIRES I YEAR FROM DATE ISSUED JOD ADDRESS 6 39 N. MVV/LS'U'/J WA,-1 CrrY/lIP ST"0)C KTp�I C� q.�2C)5 CROSS S'1'ItEE//'1��r'�oaN17q T T��U�,•� APN it-7-07-'E PAIICEL SIZE_LAND U5E APPLICATION# O\VNI:R A9X'Il lb--A./l?�/�Y�'/v(,� xejA_L PDONE(7-0*fJLf65-9.583" OwNEH ADDIti?SS 3�j�q.3 L.-fV--1 UR_ 01 Y/S"IAl En R• CONTRACI'OR VVgT K VVf=1L-� "(�'OHIVV.O L-oc'y i.-✓c• PIIt,NE(N 6J %1 CONTRACTOR ADDRESS l>•0- t3'DX J( I CITY/STATE/ZIP FA)?- x OA3 C `?-S6-R1-R9 9�—C-57 WELL DRILLING LICENSE NumBER73 I f 33 EXPIRATION DATE' 31�0� IX6. ry/_ PERFORA7'IONCONTItACTO17r wP'C-I K WP-L-(- f Et HfVG (NC WCl// PIIONE)( "q* PERFORATION CONTRACTOR ADDRESs7, SA w1 CITY/STATE/ZIP"' C-57 Well Drilling License Number -7 3 11� ESxpiratio ate / 3( 07 Bureau of Alcohol,Tobacco and Firearms-Users of 1-ligh Explosives License Number?CAO(7�3(aA ISll3LSxpir iti n Date ChP hazardous Material Transportation for Explosives !Sal bi( License Number l3'1-Lll l (►tn� Expiration Date_F/30-r-0644 -r- San Joaquin County Sheriff-Coroner Explosives Application and Permit License Number O If"-/a2 Expiration Date L16 California Occupational Safety Health-Blaster License Number $LZ Ea Expiration Date f:Z9t O REASON FOR DESTRUCTION [I Dry ❑ Replawnieut Well ❑ Caved In ❑ Pit Well Inactive ❑ Test Bole Detected/Suspected Well Water Coulmnivant(s) f1 Z^DC'6 �L0'-5 `3. +? 8 Adjacentpropertywid]contamination(Address)26(, , `^/i L- M'AY VY)L-,Swy wiaY Known Soil/Water contaminants at adjacent property_I•P14 6,, 9T'fK , 11-0r3.E-, /,Z-7Cf} EXISTING WELL CONSTRUCTION DETAII 13 Open Bolton ❑ Gravel Pack ❑ Uncascd Olherl�/Vl<.'110 W Well Log copy attached ❑ Yes No Grout Scat ❑ No ❑ Yes R below ground surface(bgs) Hole Uianieter inches Well Conductor"Casing ❑ Yes ❑ No Depth of C. ctor Casing R bgs Diameter of Conductor Casing inches Well Casing Uiameter�_inches Total Uepll I�R Depth to Water 6o R Depth OfCasing /.567 R bgs DESTRUCTION SPECIFICATION Sealing Material from R bgs to —/ (60 ftbgs Filler Material from R bgs to R bgs Well casing to be perforated by one of the following methods: from /,Ci R bgs to O�M R bgs ❑ Mills Knife Number ofcuts every_ft and/or -ICExplosives ❑ Detonating cord ❑ with projectiles every R ❑ without projectile —Detonating cord and boosters /I' with projectiles every_R without projectile ❑ Other (��-- Scaling Malcriul ❑ Neat Cenncut(94/b bug/S-6 gal,vole,) Sand Cement /0 Qoris/ gal water ❑ Ilcntonitc Pellets ❑ Bentonite(20%solids) ❑ Manufacturer Spec%solids_% Name ❑ Specs on File ❑ Specs Submitted 1'lacculcnt MdhurN Pumped ❑ Free Fall ❑ Other Seal Completion Couplctc wills Mushroom Cap 3 R bgs ❑ Complete to Existing Surface Pad 1 HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN 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. MINIMUM 24 110 Y' t AD A O/.1ICnE,REQUIRED FOR INSPECTIONS q T // CONTRACTORS SIGNATURE // C�•.�Il'TtrLTLE/+'C��N� DATE O ( I /0-5 IUMWd � } { _ DEPARTMENT USE ONLY y Application Accepted By Date � / Area _ Destruction Inspection By Date �� Employee IDt/ COMMENTS PE SC Received Checi Amount Ualc Perinll/ Invoice# 1Vd11D# Codes Indo B ush Remitted Service Request# ori! a so, $-5(-o 155,eov 3