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WELL DESTRUCTION PERMIT <br /> PUBLIC WATER SY57M ❑Yea ❑No <br /> SAN JOAom CouxTY EIWRowwNTAL HEALTH DEPAwntaENT ISM East HasMton Avenue-STOCKTON CA 95205-(209)4683420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR bisPEcT10Ns EXPIRES 1 YEAR FROM DATE ISSUED <br /> Iw <br /> Joe ADDRESS CrrYfz p <br /> CROs STREET APN DFOPARCEL SIZE(-RLANO <br /> USE APPLICATION i <br /> Ownat <br /> j OWNM ADDRESS V CRYISTATE" v <br /> i CONTRACTOR r 1I c PHONE 512 <br /> CONTRACTOR AODIItQa III RIM N. CRTf3TAT1E/Zt <br /> C-57 WELL DRa ma LWAMU NU11sElt /w4 E.11A1IDN DATE <br /> PERFORATION CONTRACTOR PHONE <br /> PERFORATm CONTRACTOR ADDREsa CmISTATrMP <br /> ❑ C-57 Wei Drilling License Number Eviration Date <br /> ❑ Bureau of Alcohoi,Tobacco and Firearms-Users of High Explosives License Number E)iration Date <br /> ❑ CHP Hazardous Material Transportation for Explosives License Number Expiration Date <br /> ❑ San Joaquin County SherlR-Coroner Explosives AppHcatiam and Perrrmlt Lio nse Number Explraft Date <br /> ❑ California Occupational Safety Health-Blester Lmmrre Number Expiration Data. <br /> REASON FOR DUTRUC" Dry ❑ Replacement Well ❑ Caved In ❑ Pit Well ❑ Inactive ❑ Test Hole <br /> Deted"Suapected Wed W arml(s) <br /> i A4&cent Property with eoeftan instlon(Address) <br /> Known SoillWater contaminants at adjacent property -_- <br /> Exwwo WELL CONSTRUCTION DETALS ❑ Open Bottom Gravel Peck ❑ Uncased ❑ Other <br /> WN Lop copy attmctmed ❑ Yes ❑ No Grout 3sal ❑ No O Yes ft below grand surface(bgs) Hole Dlarmmetsr ink hes <br /> War Conductor Casing Yes ❑ No Depthof Caslrg ft Diernater of Conductor CasWgp es <br /> Wall Casing Dlammater Inctm Total Depth R Depth to Weller ft Depth of C.04 r xbgs <br /> DESTRUCT*N SPECIFICATION UCT <br /> Soling Material from_._�ft bgs to ft bgs FlUer Material from ft bps lozU hl <br /> Well casing to be D*r_fQneted by om Of theI frOrll It bgs to san�onok <br /> ❑ Millie Knife _ Number of cub every ft andfor HEALTH p"q,tTM1 ENTM <br /> ❑ Evloslves❑ Detonating cord ❑ with projecNes everyft ❑ without projectile <br /> D Detonating cord and boosters ❑ with projectiles every ft ❑ wlthart projectile <br /> gp❑ Gthw <br /> Pdists Mg MabwW j Meg Cement(941b bag5r8 gd webw) Sand Cowwd sack moll gal water )�Bw tomo <br /> sentonks(20%saws) n A aduer Spec%solids % Name Specs on Fmile H Specs Subroftled <br /> Ptacamwd Medwd ❑ Pumped ❑ Free Far ❑ Other <br /> Seat CompWm L Complete with Mudwoom Cap r It bgs r- Complete to Endstlnp Surface Pad <br /> MINIMUM 24 HOUR ADVANCE NOTICE REGURED FOR INSPECTIONS,CALL(209)953-7697 FOR INSPECTIONS <br /> DEPARTMENT USE ON V C <br /> Application Accepted By t' /- Date o Area 7 <br /> Destruction Inspection By Date Empbyee IDik_ Aq <br /> COMMENTS <br /> PE sC Rsoslved Checkill Awwrwtt Dass Psrwdv Mrvolca s WON nil <br /> Codes kMo RerrrNled • <br /> p o IS <br /> EM 43-M ` Z ( Z 2— ` / WH1 DC3TRUCTION PERMR <br /> 111 x21 <br />