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CROSS STREET <br />JOB ADDRESS lt, 1 *.' i Pa ' crrympfCr4/0/1 66{ cfs--2_0 <br />rir rn_ <br />IOU APN MCI — t i'w R PARCEL SIZE •05 LAND USE APPLIC9ON 0 <br />OWNER Mt -11-0 i/ PHONE 204 8•38"- 8006. <br />OWNER ADDRESS ID 3crrosTATEizipfSGQ/011), GOI 615?-0 <br />CONTRACTOR I C BA PHONE 201 0 2_8" ._,, pv# <br />CITY/STATFJZ/P Dan-0 , ei'J -34.7 CONTRACTOR ADDRESS <br />yk C-57 WELL <br />PERFORATION CONTRACTOR <br />PERFORATION CONTRACTOR <br />0 C-57 Well <br />0 Bureau of <br />0 CHP Hazardous <br />0 San Joaquin <br />0 California <br />DRILLING UCENSE NUMBER U'\WD 2:2— EXPIRATION DATE DI. I - 1 2, <br />p <br /> 1 <br />PHONE <br />ADDRESS CITY/STATE/ZIP <br />Drilling License Number Expiration Date <br />Alcohol, Tobacco and Firearms - Users of High Explosives License Number Expiration Date <br />Material Transportation for Explosives License Number Expiration Date <br />County Sheriff-Coroner Explosives Application and Permit License Number Expiration Date <br />Occupational Safety Health - Blaster License Number Expiration Date <br />REASON FOR DESTRUCTION Dry 0 Replacement Well 0 Caved In 0 Pit Well 0 Inactive 0 Test Hole <br />Detected/Suspected <br />Adjacent property <br />Known SolVWater <br />Well Wet r Contaminant(*) <br />with contamination (Address) <br />contaminants at adjacent property <br />eXISTING WELL CONSTRUCTION DETAILS 0 Open Bottom X Gravel Pack 0 Uncased 0 Other <br />Well Log copy attached <br />Well Conductor Casing <br />Well Casing Diameter <br />0 Yes 0 No Grout Seal 0 No 0 Yes ft below ground surface (bps) Hole Diameter inches <br />0 Yes 0 No Depth of Coriltifpr Casing frl, Diameter of Conductor Casing Inches <br />1.9.! inches Total Depth kr,/ It Depth to Water xsu ft Depth of Casing It bgs <br />DESTRUCTION SPECIFICATION n <br />Sealing Material <br />Well casing to be <br />0 Mills Knife <br />0 Explosives <br />0 Other <br />from ki ft bgs to \to It bgs Filler Material from ft bgs to ft bgs <br />perfOrete4 by one of the following methods: from ft DOS to It bgs <br />Number of cuts every ft and/or <br />0 Detonating cord 0 with projectiles every ft 0 without projectile <br />0 Detonating cord and boosters 0 with projectiles every ft 0 without projectile <br />a ng Material <br />Bentonite <br />Placement Method <br />Seal Completion <br />r: Neat Cement (94 lb bag/5-6 gal water) Sand Cement sack mix/7 gal water Bentonite Pellets <br />(20 s lids) :1 Manufacturer Spec % solids Name :. Specs on File J Specs Submitted _% <br />k Pumped -1 Free Fl - Other <br />I Complete with Mushroom Cap '3 ft bgs Complete to Existing Surface Pad <br />I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br />JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br />CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br />WORKERS COMPENSATION LAWS. <br />lie <br />,113NIMUM )4,HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br />Dr [14 O IKKI V DATE h YL (i CONTRACTORS SIGNATURE <br /> Vitt <br />Area 4//q <br />ON Y <br />S- d <br />Co rvet <br /> Enrol <br />c-o a <br />' <br />WELL DESTRUCTION PERMIT <br />PUBLIC WATER SYSTEM 0 Yes 0 No <br />SAN JOAOUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 East HazeIton Avenue - STOCKTON CA 95205 - (209)468-3420 <br />NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED :S'S911(1CIV 11.11S DEPARTMENT USE <br />Application Accepted By <br />Destruction Inspection Inspe.ction By 4,,,,,_ Date Date <br />COMMENTS 1 „Jr .'iC ) f <br />e--.-,--(- .;.=.--r.--.)-r.—.° - eDc- <br />..s-- Q---c..4? . 1.‘a, \-/•)c-7.--t-t- <br />Date <br />PE <br />Codes <br />SC <br />Info <br />Received Check*/ Amount <br />Remitted Date j <br />Permit/ <br />Service Reg et I Invoice* Weil IDe <br />1-13C-- 0 (,t) <br />,121.. e..i1/3 1/ash <br />I ,-- 4 )s2 9 .; 13-11,11il-Ort-Ki0 <br /> ., EHD 43-08 <br />12 361 3O7— WELL DESTRUCTION PERMIT