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" WELL DESTRUCTION PERMIT = <br /> PUBLIC WATER SYSTEM ❑Yes <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE 3"°FL-STOCKTON CA 95202 - (20 )468-3420 <br /> NON-REFUNDABLE PERMIT CALL(209)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> (� /� <br /> JOB ADDRESS }- n CITY/ZIP �~ a' C <br /> CROSS STREET APN —'Z 3- q` 19 <br /> 0—f Z ,PARCEL SIZE'�' LAND USE APPLICATION# a <br /> b <br /> OWNER O'wr. _ Gly PHONE <br /> OWNER ADDRESS [/ CITYISTATE/ZI/P____'I-R•C� � ` ? . <br /> CONTRACTOR C11r, <br /> LL � S(b1' //�C�� PHONE <br /> ✓ <br /> CONTRACTOR ADDRESS r I Y CCTV/STATEIZIP ,_ <br /> Me- WELL DRILLING LICENSE NUMBER �T O ,l T <br /> . IPERFORATION CONTRACTOR kONE- �!' <br /> PERFORATION CONTRACTOR ADDRESS CIT 16WI - <br /> Ilq have e4p <br /> ❑ C-57 Well Drilling Licenstr� _ xpiration Date <br /> �u <br /> ❑ Bureau of Alcohol,Tobacco and Firearms-Users of High Explosives License�Vjua�rm� ber I I ] i Qx�it R,'g ei_,te <br /> ❑ CHP Hazardous Material Transportation for Explosives License Nllhiberlyirohm.. 'a H >,.4ti qt()) <br /> ❑ San Joaquin County Sheriff-Coroner Explosives Application and Permit License Number Expiration Date <br />€ ❑ California Occupational Safety Health-Blaster License Number Expiration Date <br /> REASON FOR DESTRUCTION ❑. Dry Replacement Well ❑ Caved In ❑ Pit Well ❑ inactive ❑ Test Hole <br /> I! Detected 1 Suspected Well Water Contaminant s) <br /> Adjacent property with contamination (Address) <br /> Known Soil/Water contaminants at adjacent property <br /> EXISTING WELL CONSTRUCTION DETAILS ❑ Open Bottom ❑ Gravel Pack ❑ Uncased ❑ Other 1 <br /> Well Log copy attached ❑ Yes ❑ No Grout Seal ❑ No ❑ Yes ft below ground surface(bgs) Hole Diameter inches <br /> Well Conductor Casing ❑ Yes ❑ No Depth of Co asing _ ft bgs Diameter of Conductor Casing inches <br /> Well Casing Diameter inches Total Dep ft Depth to Water _ ft Depth of Casing ft bgs rt; <br /> DESTRUCTION SPECIFICATION Q u ( /�'r-- c-7G d�4 � <br /> Sealing Material from 1 Y ft bgs to ft bgs Filler Material from ft bgs to ft bgs <br /> Well casing to be perforated by one of the following methods: from ft bgs to ft bgs <br /> ❑ Mills Knife Number of cuts every ft and/or <br /> 13Explosives 13Detonating cord ❑ with projectiles every ft ❑ without projectile <br /> ❑ Detonating cord and boosters ❑ with projectiles every ft ❑ without projectile <br /> ❑ Other <br /> i li Red <br /> 4 Ih ha 6 wa er and Ce n mix a! ter BF <br /> et <br /> entonite{20 ufa Sp %solid % ame Sp o i!e Sed <br /> ace a od r F OthSeal mpletion Ca ft bgs ❑ m to to Existirt ur a Pad <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> j JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> MP415UM 24 HOUR A ANCE NOTICE REQUIRED FO INSPECTIONS <br /> CONTRACTORS SIGNATURE TITLE DATE 712- <br /> 7- <br /> —T-T- <br /> 1 -J <br /> 1 .1 <br /> - <br /> 1 <br /> ENT s <br /> .E0�7ED. <br /> - � UL .2-7 <br /> SA13,lOAIN COUNTY <br /> i�TA -� <br /> eEANV <br /> LTI D1 P HSMINY_ <br /> r w <br /> s <br /> d)LDEPARTMENT USE ON� <br /> Application Accepted By - Date C)-S Area <br /> w <br /> Destruction Inspection By Date Employee ID 4-0Oc) I <br /> CO MENTS Lloe- <br /> I <br /> i <br /> I: <br /> PE SC Received Chec Amount Permit! <br /> Codes Info B ash Remitted Date Service Request# Invoice# Well ID# <br /> tF3 ra8 OCaO js� g3.a� Z? �� <br /> EHD 43-02-008 - - - a - - Well Destmaion Permit <br /> 1127/2005 <br />