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,, WELL DESTRUCTION FZI6S..°N NdtiS:Z OZO�Z Id a(uil paAI ;D;N PUBLIC WATER SYSTEM L Yes p Na SAN JOAQUIN COuNTY ENVIRONMENTAL HEALTH DEPT 1868 East Hazelton Avenue•STOCKTON CA 95205.6232-(20910583420 NON-REFUNDABLE PERMIT - - EXPIRES 1 YEAR FROM DATE ISSUED Joe ADURE5360.40_�Ashle Lane y crtvZr Stockton_ l 95212 CROs,STREET APN i t ✓) PARCEL SIZE JG'r"IAND USEAPPUCATIONO i A To ey P„�,E209- OWNER Ric 8810-4023 OWNER ADDRESSFU box c.,,T.7ZT, i n en r CA 9b23b CONTRACTORPurviance ri ers, =ic PHoNe209-887-3554 _ _ CONTRACTO3 ADORES, PO BOX 64 _ _ cn,.rsTAT.�zLP Lindenr CA 95 6 - C-57WELLDR11.L311923 oat WG LICENSE NUMB ExPlRc:nDATE Dr . Wei ,a�,uKsWAtu't, � P„ON- 53v- F-/€- 3-fs9 PERFORATION CONTttACTOR -tom ° PERFORATION CONTRACTOR ADORES r� 1 8� _CITYISTATFJZ'p r � `�p2r� C-57 Wel,Dri'lirg License Nurnberge 6 6 p Zdo(,�h�a/1e j) ,w ' Bureau of FJcohol.Tobacco and Firearms-Users of High Explosives License Number9- -O vExp Tidfh�3!e y ' CHP=arardois Niatedal Transportation for Exyiesives License Number F-,',ra0on Date 020 San Joaquin CCLnty Sh,erifl-Coroner ExI310sives Aoplica5en and Permit Li®Cse Nurnber Z�_ Expiration Cale I California Oc rp3tional Salety HeeW-13135ter License Number-JI-fAL-7.1�L — Exp ration Cale Z i REASON F ROF as DTs TReKnON ❑ Dry ❑ Replacement Well ❑ Ceved fn ❑ Pit Well 01 Inactive ❑ Test Hole Detected!Suspected Well Water Conlaminant(s)� Adjacent property with contamination(Ada rens) Lh-� Known Soil 1 Water contaminants at adlaeent property ✓JLf7�-� i EXISTING WeLL CCNSTBUCTION DETAILS b' Cpen Bct.o:n ❑ Gravel Peck ❑ Un�.aeed ❑ Othor Well Log copy attached ❑ Yes IQ' No Grout Sent ❑ No ❑ Yc--__N below ground surface(bgs) Hole Olarneter__ Inct•E5 I Well Conductor Casing Yos Wtic Depth of Conductor Casing& Rbgs Diameter of Conductor Casing _Inches Well Casing Dlemeter�lllctes Total Depth )92_tt Dopthto Water_ FrR it Depth of Caging _It bgs DF9RUCT10N SPP.CIFICATHIN Sealing Material from 0 17 bgs to �Oo K bgs Filie r Motorial ,. l j_�Stl_yj,gr4�—from_ 9 Z _it bgs to ft bgs dwell casing to be Porto rate I try one of the foflowin9 methods:_ (v-/tram 21 bgs to R bgs ❑ Mills Kntfe _%rbe;of cuts every it and 1 or 119 ExplosivesX Detonatingcord f! )6-without projectile ❑ Delonat,rg cord and boosters ❑ wilhprc)ecUeSe\cry__-_R ❑ wilhcutprojectile C other _-- ---. -- --- Sealing Material Neat Cement(96/b Dag/5-f gaJ warer) Sand Cement 14.3 sack mix 17 pal water Bentonite Pellots Bentonite(20%solids) Nlanufacturer Spec 96 solids_% Name Specs on File Specs Submitted Pfacement Method Purnpe7 Free Fall Other Seal CompEetion Cornplefe win Mushroom Cap 3 ft bgs Complete to Existing Surface Pad I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOACUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS_ I ALSO CERTIFY THAT MY REQUIRED LICENSE IS CURRENT AND ACTIVE WrfH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE«7TH ALL WORKERS COMPENSATION LAWS- . VTi �. ..,.. ._._. _.- - .. DATE 33J-;It' CONTRACTOR SIONATIJ R gr IV CE�VED SAN AP 022020 EN vq USN C j. . . . NEgLTy p MENr,4 NTy i / DEPARTMENT USE ONLY _ Aparcation Accepted By ll�/ Dale O.2 1O LJ Amo_•� C7 Ce DestnlcLon Inspection By Dale Employee IDS COtAtd NTS G e �✓' I0 r PE SC Received Che Amount Date Permit) Invoice N Well IDs ^' Codas Info a Remitted erwice Request N I WELL DESTRUCTION PERMIT EMD n3be 7 1(1,547 Z d VLSUH150Z QUA S.lall!JQ BOUeiA.lnd deg'.60 OZ l0Jdd