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/ • 1 R WELL DESTRUCTION PERMIT Q PUBLIC WATER SYSTEM❑Yes ❑No SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE 3"v FL-STOCATON CA 95202-(209)468-3420 NON-REFUNDABLE PERMIT C.1 LT;(209)953-7697 FOI?Ivsr@;C.9'tCl rS EXPIRES I YEAR FROM DATE ISSUED JOBADDRESS A131 Wit uni -rhik,Q�j Ave, CITY/ZIP MAn-�tJ'9t.. , A 9y33 `( CROSS STREET PHI T APN 1991 1Q96--7 PARCEL SIZE LAND USE APPLICATION# I o A a a09- 30—a'1 i'7 A OWNER �ye J T/�a�Y�^1� • PHONE -6-114- 5 y i S!� (4-1Q, 1 1 l ll<G �� 1 h� CITY/STATE/ZIP C J- G! OWNER ADDRESS G`�r��''-A 1y.• ^ /1 1� Tom' ,t /]- CONTRACTOR �./4Ty�K(/►vt T'n��Q r•(.�Tl�/Y��I�T r PHONE (4toS— J-11-.I. M Q i CONTRACTOR ADDRESS ,J�D� IQLiIL�-I•V� 1 k4— CTI'Y/STATE/ZIP �(�K1f/n 1 rja- _( x C-57 WELL DRILLING LICENSE NUMBER 5 t aat� EXPIRATION DATE PERFORATION CONTRACTOR 6- ►\S PHONE PERFORATION CONTRACTOR ADDRESS tO �C. 5 r 9 CITYISTATE/ZIP i ❑ C-57 Well Drilling License Number Expiration Date ❑ Bureau of Alcohol,Tobacco and Firearms-Users of High Explosives License Number Expiration Date ❑ CHP Hazardous Material Transportation for Explosives License Number Expiration Date " w ❑ San Joaquin County Sheriff-Coroner Explosives Application and Permit License Number Expiration Date ^ ❑ California Occupational Safety Health-Blaster License Number Expiration Date REASON FOR DESTRUCTION ❑ Dry ❑ Replacement Well ❑ Caved In ❑ Pit Well ❑ Inactive ❑ Test Hole Detected/Suspected Well Water Contaminant(s) 111TYFf'� ` Adjacent property with contamination(Address) ,( Known Soil/Water contaminants at adjacent property I Q I N i EXISTDVG WELL CONSTRUCITONDETAIIS ❑ Open Bottom BI Gravel Pack ❑ Uncazed ❑ Other Well Log copy attached ❑ Yes ff'No Grout Seal ❑ No ❑ Yes ft below ground surface(bgs) Hole Diameter inches Well Conductor Casing ❑ Yes M"'No Depth of Conductor Casing ft bgs Diameter of Conductor Casing inches Well Casing Diameter tt inches Total Depth " Depth to WaterN(Sr It Depth of Casing ft bgs DESTRUCTION SPECIFICATION 0I Sealing Material from ft bgs to_ ft bgs Filler Material from ft bgs to ft bgs Well casing to be perforated by one of the following methods: from �t f It bgs to g If'1• ft bgs ❑ Mills Knife Number of cuts every ft and/or )r Explosives ❑ Detonating cord ❑ with projectiles everyft ❑ without projectile ;ff Detonating cord and boosters ❑ with projectiles every•_ft ❑ without projectile ❑ Other Sealing Material X Neat Cement(94 Ib baglJ-6gat water) ❑ Sand Cement sack mix/7 gal water ❑ Bentonite Pellets ❑ Bentonite(20%solids) ❑ Manufacturer Spec%solids % Name ❑ Specs on File ❑ Specs Submitted Placement Method❑ Pumped ❑ Free Fall ❑ Other Seal Completion ❑ Complete with Mushroom Cap 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 JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION LAWS. �1I\I1It!'I 24IIC)ti12:1DZ'.1vC'r �C)'I'iCF.REQUIRED FOR IXSPEC'I I(3 \S CONTRACTORS SIGNATURES .� �L/ TITLE 1•l Q I _DATE ! 1 I 1 ) _...-;.....:_.....:...................................._._._........... . _.. ..... -- - ......x.........._... ,........ Imo_. ................ : ._. ... ..... i ..f._....._ ...... t ...... ,....... I .. 3 .._ +— I DEPARTMENT USE ON �J / 4 Application Accepted By Date ` 0 ( Area ( 2- ( I Destruction Inspection By Date H 8 Employee ID# COMMFNTc t ov rJA 50;- L1��Gf 11 � t r PE SC Receive Check#/ Amount Permit/ Codes Info BY Cash Remitted Date Service Request# Invoice# Well ID# 373 t ab S A Sa K r9 y49015(9305' 1 1 Imar«is