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1 �a •� j� " qz � 7�`�t'���t�rF� � �iF}t�a1' �� � ' ;: :r �o �+ �?�P ��,t'sT` Fr -�t � ro� , <br />;' ors. � ... . a , r ,.,.,. �4tn ,u�:g . �ii� E..,• »5'`�t� . •A+ ',. . •. '' <br />WELL DdSTRIlCI`I'ION PERMIT <br />PUBLIC WATER SYSTEM ❑ Yes ❑ No <br />SAN JOAQUIN COIIHry Et*IR)f RWNTAL HEALTH DEPARTMENT 1888 East Hazelton Avenue - STOCKTON CA.95205 - (209) 468-3420 <br />NON -REFUND BLIOEsigir . CALL (2091953-7697 FOR INSPECTIONS EXPIRES 1 Y,—c,--n —SSU <br />m <br />rM <br />JOeAlrptees <br />/� ED <br />Cnv/Lv_SCUION, I.GV • Q�3Z0 <br />CROSS ST •''" 3 iPN7 & I -ISO- NOPARCEL <br />8Q QLLANDUBEAPPLICATtoN'If <br />Co. <br />PHON 424 <br />owwERwn IWO <br />CdlON. <br />nrss`'.at <br />Crtr/sn►TElot+ i A 4937,D <br />PHONE_aQ& 19F2.4 <br />CONTRACTOR!. r 1' I` :. <br />. <br />crtT/sTtTEiz�11rL0 GQi• 453li7 <br />_� C�7 WIJ L DRILLWO: LICEf16E NUMeitiR: <br />ExpinATION DATES � '�O • 7.� <br />PERIfORATICN COMTYA o <br />PHONE . <br />1`131FORATION•CDij' RAMOR ADD REa9 <br />CRY/STATEMP <br />❑ C-57 WOO DllUing <br />License Number Expiration Date <br />❑ Bureau gfAlirifiol, Tobtpco end Fltnffns - Users of High Explosives <br />License Number Expiration Date <br />b CHP kWardous MAW,iW Trsnsporta(lon for Explosives <br />License Numbs( Explraflon Date <br />❑ San JoaljulnCounty Sheitff-Coroner Explosives Application and Permit <br />License Number Expire Von Date <br />O: , Ca5lomle Occupational Sa(eljl'Heaith * Blaster <br />License Number Expiration Date <br />RimoN HIR DESTRUCTION Dry p Replacement Well ❑ Caved In ❑ Pit Well ❑ Inactive ❑ Teat Hole <br />Detected/Suspeoled Well Wits :Contamiriant(s <br />Adjacent property with eontsminidbn (Address,) <br />Known.So[Mater contaminants at adjacent property <br />E)aSTLNG WELL CoftTiricTigH❑ Open Bottom Gravel Pack ❑ Uncased ❑ Other N <br />Well Lou copy attached `❑ Yes No Grout Sul ❑ No ❑ Yes <br />_ It below ground surface (bgs) Hole Dlernmer ett�jr/ <br />Well Conductor Casing ❑� �Yes d r No Depth of Conch -1 Casing ft bbos Diameter of Conductor Casing Inches <br />Well Casino Total �� r_ 7 T_ <br />Dlsmstpk�_Mches Depth it Depth to <br />Water_ it Depth of Casing it <br />'DESTRUCTION SPECT WAT1ON qn + <br />0 <br />Sealing Material from =ft bgs to it bgs Filler Material <br />from it bgs to it bgs <br />Well Casino to be Oerf Z} tedoy one of the following methods: <br />from ft bgs to tt bgs <br />❑ MIAs Knits Number of cuts every ft and/or <br />❑ Explosives ❑ Detonating cord ❑ with projectiles every <br />it ❑ without projectile <br />❑ Detonating cord and boosters 13with projectiles every <br />ft 13 without projectile <br />❑ Other . <br />set ng MetsNel fl Meet Cement(9416 bay/5-6 gel wafer) n Sand Cement <br />sackmlxq pal water n Bentonite Pellets <br />Ssntoni(e (20 olids) o Manufacturer Spec % solids_% Name <br />D Specs on Flle U Specs Submitted <br />pliCi ht Method Pumped n Free Fall n <br />Other <br />Seal Completion . Cattplete.with Mushroom Cep _ ft bgs <br />U Complete to Existing Surface Ped <br />I HEREBY'CER71FY THAT T-HAVE.PRFPARED THIS APPLICATION AND THAT. THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br />JOAQUIN COUNTY 0g0IHAN.CE8+ STATE Uft AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE ,IS <br />CURRENT AND ACTNE WITH: THE•:CALIFORNIA CONTRACTORS STATE'LICENSE BOARD AND THAT I AM IN WITH ALL <br />WORKERS COMPENSATION LAWS. <br />DEPARTMENT .UBE ONLY <br />Application Accepted By Z Dale 3V Q"A5 Area q <br />Destruction Inspection By Date Employee ID! <br />COMMENTS <br />PE SC Received Chackt/ Anlount Psrmitl <br />Codes-: Info fresh Riinitled <br />Date Ser0loeRe uest7l Involeeil WaIIIDA <br />y3 .. oto. tsar._.LOMIM <br />.ED�g-0B` WELL DESTRUCTION PERMIT <br />C, MENT <br />E/VSD <br />302020 <br />QNMECOUNry <br />)EP <br />ARTMEN7. <br />