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1805 East Hazelton Avenue - STOCKTON CA 952054232 - (209) 468-3420 EXPIRES 1 YEAR FROM DATE ISSUED SAN JOAQUDI COUNTY ENVIRONMENTAL. HEALTH DEPT NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS Application Accepted By Destruction Inspectio?By A _ COMMENTS Ci.0 _ kri•KM DEPARTMENT USE ONLY Date Area Si rfef ey Dale Employee VS revised 4/14118 El-ID 43-08 WELL DESTRUCTION PERMIT 2,5Al 4h2-4 /q63?61 WELL DESTRUCTION PERMIT PUBUC WATER SYSTEM 0 Yes 0 No JOB ADDRESS --/ c2isq 4Th/14- 1,1 1-1- kik• CITY/ZIP Tritcq , CA elS343 4 CROSS STREET P il AP N i ( 301 6 5r2._ PARCEL SIZE LAND USE APPUCATION B OWNER I-. f - I I, Clu:',.1, ')C!r-i.s..Li,,,,,lt:(.1 raine.f.jiip PHONE OWNER ADOREs5 1717 /VIC )< l rM1 /VP- 5 te /C1 a-6 CITY/STATEIZip De\ i L,S 1-X 7 S010 3 7.. CONTRACTOR ite..1kilelak1 Pr I a 4.s VIC) PHONE qtte - 3 $3 -3434 CONTRACTOR ADDRESS fb 67 p. acnk5-s- CITY/STATFJZJF 1aCreay9 , CA 41 S5-1-1 C-57 WELL DRILLING LICENSE NUMBER 00 S 0 2- EXPIRATION DATE it, I ;C:1( 2.. I PERFORATION CONTRACTOR AL.3401V:1 AAA< iti.i 11 SCV\I)IA W.- f:- PHONE - - - . -- 2.7_ PERFORATION CONTRACTOR ADDRESS 41 0 I letlIALL1/1 Pct 14-3 ,41 crrasTATErup IPA Z ' '_ • a S5i2- _S1- 0 C-S7 Well Dating License Number oh/awe - - Axpiration Date Bureau of Alcohol, Tobacco and Firearms - Users of High Explosives License Number ' ' C 0..:),) ' Expiration Date CHP Hazardous Material Transportation for Explosives License Number /J ' 7 4- 1 r Expiration Date . San Joaquin County Sheriff-Coroner Explosives Application and Permit License Number d 1- 0 ::: Expiration Date 217 d California Occupational Safety Health - Blaster License Number 4E51 . Expiration Date 3 , REASON FOR DuarnucTioN 0 Dry 0 Replacement Well 0 Caved in D Pit Well [1],1iactIve 0 Test Hole Detected / Suspected Well Water Contaminant(s) Adjacent property with contamination (Address) Known Soil / Water contaminants at adjacent property Exismo WEU. CONSTRUCTION DETAlta 0 Open Bottom 0 Gravel Pack 0 Uncased 0 Other Well Log copy attached 0 Yes 12?"--No Grout Seal 0 No CI Yes ft below ground surface (bps) Hole Diameter ic. inches Well Conductor Casing 0 Yes 0 No Depth of Conductor Casing ft bgs Diameter of Conductor Casing Inches Well Casing Diameter loll Inches Total Depth q f) ft Depth to Water 1 3 ft Depth of Casing ft bgs DESTRUCTION SFECTEICATION Sealing Material from qo ft bgs to 4- ft bgs Filler Material from ft bgs to ft bgs Well casing to be perforated by one Otte followino methods; _ from 70 ft bgs to JO ft bgs 0 pills Knife Number of cuts every ft and I or , 0'"Exploalves 0/Detonating cord 0 with projectiles every ft without projectile 0 Detonating cord and boosters 0 with projectiles every ft CI without projectile 0 Other Sealing Material Neat Cement (94 lb bag / 5-6 gal water) Sand Cement A i sack mix 1 7gal water Bentonite Pellets Bentonite (20% solids Manufacturer Spec % solids % Name Specs on File Specs Submitted Placement Method umpe Free Fall , , Other Seal Completion Complete ushroom Cap 1 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 UCENSE IS CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION LAWS. MI CONTRACTORS SIGNATURE s flTu MUM 8 OUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS DATE Li 8 )- f c es A77Y1z HO) 5 fre MA p PE Codes SC Info Received Check'', Cash Amount Remitted Data I t Permit/ e Request 1 v\r Invoice ii Well ID# 93-7 1 Ik 1 c)52 17;,_, t icis- quip vuoi410,0