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WELL DESTRUCTION PERMIT <br /> PLMM WATERS MM p Yes ONO <br /> SAN JOAQUIN COUNTY ENMRONYENTAL HEALTH DEPT 1666 East Haniton Avenue-STOcxTON CA 9520E41232-(209)4693420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> Joe AooaEsa <br /> CRM STREETF�1R JA t!�t'L.���� APN 1 7,3 -ga*-L3 7tr,PARM SUE_LAWUse Am"Tom 6 <br /> OWNER NE P- <br /> NOn 14 633 `73 Z.3 <br /> OWNER ADowss Zt.SoA)C is f3 Cm/8rATEIZW JEW—j4.lei CA ?A <br /> CowrRACTOR PWW 2r,q -.-'R -7 4P- <br /> CONTRACTOR ADDREsa ✓ LC M` , CRYISTATE/IIP <br /> C-57 WELLDRILLING Lxa NSE NUMBER1 AP`t ExPWATM DATE P-,!!S _e <br /> PERFORATION CONTTiACTOR�!':/ PHONE <br /> "7 <br /> PERFmAT*N CONTRAcrOR AboREss Cml$TATFILP <br /> ❑ C-57 Well Drilling License Number Expiration Data <br /> Bureau of Alcohol,Tobacco and Firearms-Uses of High Explosives License Number Expiration Date <br /> CHP Hazardous Material Transportation for Explosives License Number Expiration Date <br /> San Joaquin County SherM-Coroner Explosives Application and Permit License Number Expiration Date <br /> Caltfomia Occupational Be"Hea161-Blaster License Number Expiration Date <br /> REANON FOR DESTRUCTION ❑ Dry ❑ Replaoemam Well ❑ Caved In ❑ Pit WON ❑ Inactive ❑ Test Hail <br /> Detected I Suspected Well Water Contaminant(s) <br /> Adjacent property with contamination(Address) <br /> Known Soli/Water contaminants at adjacent property <br /> ❑ Open Bottom ❑ Gravel Pack ❑ Uncased ❑ Other <br /> Wail Loy copy ettactred ❑ Yes ❑ No Grout Seal ❑ No ❑ Yes ft below ground surface(bye) Hola Olamster krctfes <br /> Well Conductor Caving❑J1Yes ❑ No Depth of Conductor Fasinp ft bps Dismater of Conductor Casing inches <br /> Well Casing Dlamatar � L t i 1tha s Total Depth it Depth to Wear R Depth of Casing it bgs <br /> or 11 amn' I <br /> Sealing Madafal from It bgs 4W liar Material front It bgs to BO(V bgs <br /> Y <br /> ngto baby om of the followi from ft bgs to ft bgs <br /> iaKnee Number of ads every_,"�2„� ftand!o plosives❑ ng cord ❑ with projectiles every It ❑ without projectile r! <br /> ❑ Detonating oord and boosters ❑ with projectiles every it ❑ without projectile /% <br /> Sealing Materia! Nast Cement(94 Ib bag/54 gat watarj Sand Cement sack m&17 gal water Bentonite PNNtsi`o <br /> Bentonks(20%solids) Manufacturer Spec%solids__% Name Specs on Fib Specs Submitted /t <br /> Puwoffmnt Method Pumped Free Fa a r Other r��� <br /> Seat Completion Compote with Mushroom Cap ' ft bgs Cong Complete to ExlsNSurface Pad '"'�fll v �9 <br /> 1 HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE ��U/N C0U <br /> JOAQUIN COUNTY ORDINANCES,STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED U. }J NMFN N>}. <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL bA�yy,TA( <br /> WORKERS COMPENSATION LAWS. FNT <br /> IML <br /> d$HOUR ADVANCE NOTICE REQUIRED 'OR INSPECTIONS <br /> commAcmu s..Tu T. .3' DATE <br /> ...._ .... . µ- <br /> ._-�.......... .. .}. w_ <br /> It _. <br /> ............... ...... ....... <br /> i <br /> a <br /> ...- - - :: .......� .... _ . . .: .................. ........ <br /> _ r <br /> s s <br /> w <br /> EP TMENT USE ONLTf, <br /> Application Accepted Byoats r Area <br /> Destruction Inspection ey Date 1AMEmployee Ick_ <br /> MMEN <br /> , <br /> i <br /> PE Sc Racalwed Amwfflted Ode Sarvka�R wt»tt 11 Invoke• Wee IDM <br /> Remit <br /> UAIUSS <br /> EHO 43.08 WELL DESTRUCTION PERMIT <br /> revised 414118 <br />