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WELL DESTRUCTION PERMIT PUBLIC WATER SYSTEM ❑Yeso SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 East Hazelton Avenue-STOCKTON CA 95205-(209)468-3420 NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS +EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS SSS - Z CITYRIP r�'�_'�f �7 CROSS STREET � ) APN 'i �G'TL'—C /�PfAR_CEL S F�j�LLAND USE APPLICATION q OWNER - N / 'It OWNER ADDRESS / "CITY/STATE/ZIP CONTRACTOR /� L' /C////•/V �/ -- j PHONE CONTRACTOR ADDRESS� CITY/STATE/ZIP C-57 WELL DRILLING LICENSE NUMBER ` EXPIRATION DATE //3'Z" PERFORATION CONTRACTOR PHONE PERFORATION CONTRACTOR ADDRESS CITY/STATE/ZIP ❑ C-57 Well Drilling License Number Expiration Date ❑ Bureau of Alcohol.Tobacco and Firearms-Users of High Explosives License Number Expiration Date ❑ CHP Hazardous Material Transportation for Explosives License Number Expiration Date ❑ San Joaquin County Sheriff-Coroner Explosives Application and Permit License Number Expiration Date ❑ California Occupational Safety Health-Blaster License Number Expiration Date REASON FOR DESTRUCTION ❑ Dry (Replacement Well ❑ Caved In ❑ Pit Well ❑ Inactive ❑ Test Hole Detected/Suspected Well Water Contamj ant(s) Adjacent property with contamination(Address) Known Soil/Water contaminants at adjacent property EXISTING WELL CONSTRUCTION DETAILS V Open Bottom ❑ Gravel Pack ❑ Uncased ❑ Olher Well Log copy attached ❑ Yes ❑ No Grout Seal ❑ No ❑ Yes It below ground surface(bgs) Hole Diameter -_. Inches Well Conductor Casing❑ Yes ❑ No Depth of Conductor Casing _ it bgs Diameter of Conductor Casing inches Well Casing Diameter__inches Total Depth !��-�_11=7 Depth to Water_. /_�_.It Depth of Casing _-_ It bgs DESTRUCTION SPECIFICATION t / Sealing Material from J5___ft bgs to__Q_. ._ it bgs Filler Material_ from-, -----ft bgs to ft bgs Well casing to be perforated by one of the following methods: from It bgs to .,.--. ft bgs ❑ Mills Knife Number of cuts every ft and/or ❑ Explosives❑ Detonating cord ❑ with projectiles every it ❑ without projectile ❑ Detonating card and boosters ❑ with projectiles every it ❑ without projectile ❑ Other Sealing Material Neat Cement(94 Ib bag/5-6 gal water) Sand Cement -3 sack mix17 gal water Bentonite Pellets Bentonite(20%solids) Manufacturer Spec%solids___% Name -_._ Specs on File Specs Submitted Placement Method Pumped Free Fall Other^ F y r�`�L ' Seat Completion/,U Complete with Mushroom Cap it bgs Complete to Existing Surface Ped 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 LICENSE IS CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION LAWS. H9 C/y�VA�lNCE NOTICE REQUIRED FOR INSPECTIONS CONTRACTORS SIGNATURE TITLE ATEZZZ w= ti W 41i Q'- QJ 4� a TIrC5 s IT \ EPAFjrTM Nr USE ON Y T Application AcceptedRy_ _ /r / �z �_- _ Date ` ` A. -- Destruction Inspection By - -- --.-t Date -_-- III --_-.--- Employee IDff /�/- -. COMMENTS — ��V �1 PE SC Received Check#/ Amount Permit/ Codes Info By Cash Remitted Date _Service Request# Invoice# Well I k 4 EHD 43-08 - I WELL DESTRUCTION PERMIT 4/30/12 1 rt? Cyc r r r