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WELL DESTRUCTION PERMIT <br />PUBLIC WATER SYSTEM C1 Yes 0 No <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1363 East Hazelton Avenue - STOCKTON CA 95205 - (209) 468-3420 <br />0E — CALL 12091953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />NON-REFUNDABLE R <br />Joe ADDRESS trylzp ION, Goi qlrow <br />UU1- PARCEL SIZE USE APPLICATION # <br />CROSS STREET AP N -(L <br />A -1 117`,Y�� PHONE-24.%-;%ft <br />-LAND <br />ob <br />OWNER <br />ATEP <br />CrTYMM <br />ficAlON. CA, <br />OWNER ADDRESS <br />PHONE A- <br />RI 18:7Z <br />CONTRACTOR <br />CONTRACTOR ADDR...CrTYISTATEIZJP <br />C-57 WELL DRILLING LICENSE NUMBER_ EXPIRATION DATE <br />PERFORATION C.NM.TOP-- PHONE <br />PERFORATION CONTRACTOR ADDRESS crry/STATEMP <br />PF Check#/ <br />'��d ';k Ciish'; <br />[I C-57 Well Drilling License Number <br />Expiration Date <br />• Bureau of Alcohol; Tobacco and Firearms - Users of High Explosives License Number <br />Expiration Date <br />• CHP Hazardous Materiat! L Transportation for Explosives License Number <br />Expiration Date <br />• J ­ ulh County Sherlif-Coroner E�'plosNes Application and Permit License Number <br />San oiq <br />ExplratIon Date <br />. <br />Califolpla ipstional,Safety Health �Blaailsr License Number <br />Expiration Date <br />REASON gpj$fRUCTION - 'bC'Dry I.. [J floplacementWBII 0 Caved In 0 Pit Well <br />D Inactive 0 Test -Hole <br />bqtecfed/SUspqctjd Well Watir'Contarninant(s) <br />WELL DESTRUCTION PERMIT <br />Adjacdht property with contamination (Address) <br />Known SOIVWatet contsminants, at . adjacent prope <br />EXISTING WELL CdR3M"1WLQKMA 0 Open Bottom Gravel Pack 0 <br />Untried 0 Other <br />chL <br />Well Log copY, attached CI Yes [3 No ProutSeal 0 No E3 Yes _ it below ground surface (bgs) Hole Diameter Ines <br />Well Conductor,CssIng,0 Yes [3 NO b soth of. Conductor Casing _it Diameter of Conductor Casing_ Inches <br />- <br />Well Casing Tatal Depth LUM it Depth to fttr­it <br />' g <br />Depth of Casing _ it bgs <br />DESTRUCTION SPEOFICAMON <br />Sealing Material from It bgs to it bgs Filler Material <br />from _ it bgs to it —bgs <br />Wall casing kd;bo geddrated I by one of the fallowing methods; from <br />— it bgs to — it bgs <br />_,Number of cuts every _ <br />13 MiIiiand(or it <br />0 Exploi.4 0 Detonating Cord 11 with projectiles every tt <br />0 without projectile <br />b Detonating cord and boosters 0 with projectiles every it <br />0 without projectile <br />0 Odlar <br />S 0rIg Matarj.ml n Nest Cement (94 lb bag/5-B gal water) I I Sand Cement _sack mix/7 gal water nBentonite Pellets <br />BsnI0hI*(2O%solids) .Ci k6nuilacturer Spec% solids—% Name <br />D Specs onFile U Specs Submitted <br />plsderriafltj"qd n Pumped n Free Fall n Other <br />all , te, comp It bgs U Complete to Existing Surface Pad <br />Seel Co� on is withiMushroorn Cap <br />I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLIUAIIUM APILF MAI Inc WUMN YVILL, CC WVM= In <br />JOAQUIN COUNTY;ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED ,LICENSE IS <br />CUh`R . , WITH"THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br />WORK06i ATION LAWS- <br />10 <br />M N MUM-49UR.ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br />. I <br /><Z.•IO <br />CONTRACTORS SIGNATURE DATE <br />Appftstlon Accepted By <br />By <br />COMMF S <br />DEPARTMENT USE <br />Date <br />Date <br />ONLY <br />mwwl <br />Area <br />Employee IDR 4S <br />PF Check#/ <br />'��d ';k Ciish'; <br />Amount. Data <br />emitted <br />Permit/ <br />Service R <br />Invoice III Well ID* <br />EHD 4bs <br />L2115�,&I-'I <br />WELL DESTRUCTION PERMIT <br />