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} � WELL.DESTRUCTION PERMIT PUBLIC WATER SYSTEM ❑Yes SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE 3K9 FL-STOCKTON CA 95202 - (20 }468-3420 NON-REFUNDABLE PERMIT CALL(209)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS 7- Adpr CITYIZIP Q G (, a APN - /90 f 1 PARCEL SIZE/�`LAND USE APPLICATION# tv CROSS STREET D OWNER vy►t W PHONE 493 X33 p OWNER ADDRESS G CITYISTATEIZI//P CONTRACTOR PHONE i0 Z CONTRACTORADDR£SS J � / ' � r� CITYISTATEIZIP 2 /CICK a, C-57 WELL DRILLING LICENSE NUMBER O Eft T A - PERFORATION CONTRACTOR HONE" B F k PERFORATION CONTRACTOR ADDRESS CITAUffff1 P r " have ` ' ❑ C-57 Well Drilling Licensr�ftt i Expiration DateU� ❑ Bureau of Alcohol,Tobacco and Firearms-Users of High Explosives License�u�Jmber I� L U I L x a t ❑ CHP Hazardous Material Transportation for Explosives License n dy1r0Pm. 'a] H K*WOLg on ❑ San Joaquin County Sheriff-Coroner Explosives Application and Permit License Number Expiration Date ❑ California Occupationai Safety Health-Blaster License Number Expiration Date REASON FOR DESTRUCTION ❑ Dry Replacement Well ❑ Caved In ❑ Pit Well ❑ Inactive © Test Hole Detected/Suspected Well Water Contaminant s) Adjacent property with contamination (Address) Known Soil 1 Water contaminants at adjacent property EXISTING WELL CONSTRUCTION DETAILS ❑ Open Bottom ❑ Gravel Pack ❑ Uncased ❑ Other �} Well Log copy attached ❑ Yes ❑ No Grout Seal ❑ No ❑ Yes ft below ground surface(bgs) Hole Diameter inches Well Conductor Casing ❑ Yes ❑ No Depth of Co asing ft bgs Diameter of Conductor Casing inches Well Casing Diameter inches Total Dep ft Depth to Water -a fl Depth of Casing ft bgs DESTRUCTION SPECIFICATION tyl 1�7Ce ! ,p 1 Sealing Material from ft bgs to ft bgs Filler Material from ft bgs to ft bgs Well casing to be perforated by one of the following methods: from ft bgs to ft bgs ❑ Mills Knife Number of cuts every ft and/or } ❑ Explosives ❑ Detonating card I 1 ❑ with projectiles every ft ❑ without projectile ❑ Detonating cord and boosters ❑ with projectiles every ft ❑ without projectile ❑ Other Sealing Material ❑ Neat Cement(941h hag/S-6 gal water) ❑ Sand Cement sack mix 17 gal water ❑ Bentonite Pellets P'l—entonite(20%solids) ❑ Manufacturer Spec%solids % Name ❑ Specs on File ❑ Specs Submitted Placement Method gimped ❑ Free Fall ❑ Other _ Seal Completion ❑ Complete with Mushroom Cap 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. 1 ALSO CERTIFY THAT MY REQUIRED LICENSE IS CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT 1 AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION LAWS. MI M 24 HOUR A ANCE NOTICE REQUIRED FO INSPECTIONS ^[� �j �] CONTRACTORS SIGNATURE T[TLE DATE L h F f/ - �� _OC UN -SANIOAE4T. &VIRONMN tEALTN,ORPARTM1rNT - r DEPARTMENT USE ONL s Application Accepted By Date ZL i�S Area Destruction A Date Employeeiggi CO MENTS I r 17 r"h�••+� d >i1 b PE S Received Chec Amount Date ermitl invoice# well ID# Codes Info B ash Remitted Service Request# 4-3•U9 0&8 Well Destruction Pami EHD 43-02-0011 ]12712005 - --- -- —