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ADJACENT PROPERTY AT WITH SOIL/WATER CONTAINING <br />JOB ADDRESS Ripona Market at 223 W. Washington Street Ripon / „ctliMITISERCES Crry/Lip <br />CONTRACTOR V&W Drilling / M.J. Kloberdanz & Associates 916-777-4100 / 209-577-8186 PHONE <br />CONTRACTOR ADDRESS M.J. Kloberdanz & Associates, P.O. Box 5 7 6 9 8 1CiTY/STATE/ZiP Modesto, CA 95357 <br />WELL WATER WITH CONTAMINANTS. <br />CONTAMINANTS OF <br />LICENSE <br />CIX C-57 Well Drilling <br />Bureau of Alcohol, Tobacco and Firearms - Users of High Explosives <br />CHP Hazardous Material Transportation for Explosives <br />San Joaquin County Sheriff-Coroner Explosives Application and Permit <br />Califomia Occupational Safety Health - Blaster <br />License Number C - 5 7 - 7 2 0 9 0 4 <br />License Number <br />Expiration Date 4 - 3 0 - 0 7 <br />Expiration Date <br />License Number Expiration Date <br />License Number Expiration Date <br />License Number Expiration Date <br />WELL DESTRUCTION 0 Open Bottom 0 Gravel Pack 0 Uncased <br />Well Diameter 2 in Total Depth 35,50,60 ft Depth to Water -25 <br />Sealing Material Meat Cement (99 lb bag / 5-10 gal water) 0 Sand Cement <br />0 Bentonite (20% solids) 0 Manufacturer Spec % solids % Name <br />E(Other Monit oring Wells <br />ft 0 Casing to be Perforated from ft to ft <br />sack mix I 7 gal water 0 Bentonite Pellets <br />0 Specs on File 0 Specs Submitted <br />Placement Method CPumped 0 Free Fall 0 Other <br />Complete with Mushroom Cap 3 ft below grade 0 Complete to Existing Surface Pad <br />RECEIVED <br />WELL J... ,STRUCTION PERMIT ADD ,4DUM <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE 3 ° FLOOR - STOCKTON CA 952 - (209) 468-3420 <br />NON-REFUNDABLE PERMIT CALL (209) 953-7697 votz INspvc-rioNs EXPIRES 1 YFWIRCOIMMINEMTH <br />WELL LOG COPY ATTACHED 0 Yes <br />WELL WITH CONDUCTOR CASING 0 Yes <br />12XN0 Logs on file a DEH DIAMETER OF CONDUCTOR CASING (MW -4) 8 5/8 inches <br />DIX No DEPTH OF CONDUCTOR CASING ft bgs <br />METHOD OF WELL CASING PERFORATION NA <br />Well casing to be perforated from ft bgs to ft bgs <br />Mills Knife <br />Explosives <br /> Number of cuts every ft and/or <br />Detonating cord only with or without projectiles every ft <br />Detonating cord and boosters with or without projectiles every ft <br />Other <br />Other <br /> <br />I HEREBY CERTIFY THAT I HAVE THE AUTHORITY TO COMMIT THE ACTIVITY DESCRIBED ABOVE FOR THIS CONTRACTOR, THAT I HAVE <br />PREPARED THIS APPLICATION AND THAT THE WORK WIL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE <br />LAWS, RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS CURRENT AND ACTIVE WITH THE CALIFORNIA <br />CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION LAWS. <br />U M 24 HOUR ADVANCE NOTICI:: fa:W:11WD FOR INSPELUONS <br />SIGNED TITLE DATE <br /> <br />DEPARTMENT USE ONLY <br />Application Accepted By V1 /4>4.A 4Ares 1".• Date I 0/26(06 <br />Destruction Inspection By V 44& t.4 ....6 C.V.... Date I I/ z406 <br />Area -( <br />Employee ID# <br />6 2c't <br />COMMENTS &-XCelp4 41 ir ai- 4 C exAct4.4r,40d c_ck5t▪ A..‘3 t,14 1.„( cUniii ne.4-if, t",.. vvi e., s4 ia.--t <br />r ,-, \AAk--t•CA- tnit4— e"--... On l.".., k tr/L4,-.. <br />PE <br />Codes Codes <br />SC <br />Info <br />Received Check#/ <br />Cash <br />Amount <br />Remitted Date Invoice # Well ID# Servic—Ttrqur <br />15-e2 <br />3sD3 <br />140 <br />a <br />4 ( 3/ A .3%K. 0. I 012.& Lft L, ci cl_____ _._ <br />OCT ?.2 5 2006 :ssmiaaV anS EHD 43-02-001 <br />3/3/2004 <br />Well Destruction Permit Addendum.doc