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WELL DESTRUCTION PERMIT <br />� <br />PUBLIC WATER SYSTEM ❑ Yes ❑ No <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 East Hazelton Avenue - STOCKTON CA 95205 - (209) 468-3420 <br />NON-REFUNDABLE PERMIT CALL (2091953-7697 FOR INSPFCTIONR EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS 4 f'.'l �R <br />CITY/ZIP M �f��C'1t- G -7/I 9 _3 jiL <br />CROSS STREET 4-y r Z C% AP 9f0W' 300 <br />PARCEL SIZES LAND USE APPLICATION # <br />nn <br />OWNER S�P�LL� P6LIQ4ryu_12s- rr/� <br />PHONE 2ayZ-/` <br />1 S; da, <br />��..,� <br />Z <br />OWNER ADDRESS ! ,3 .-4, �t i <br />W' 2Y� <br />CITY/STATE2IP l�ii %/^!c <br />CONTRACTOR <br />PHONE 1.5 Z0__'Z X/ <br />CONTRACTOR ADDRESS ' I /%� I <br />CITY/STATE/ZIP- ly, j1- ec,46) ' <br />/ /' .� <br />C-57 WELL DRILLING LICENSE NUMBER �(l�, �/- <br />EXPIRATION DATE 6�1 <br />PERFORATION CONTRACTOR <br />PHONE <br />PERFORATION CONTRACTOR ADDRESS <br />CITY/STATE/ZIP <br />❑ C-57 Well Drilling <br />License Number Expiration Date <br />❑ Bureau of Alcohol, Tobacco and Firearms - Users of High Explosives <br />License Number Expiration Date <br />❑ CHP Hazardous Material Transportation for Explosives <br />License Number Expiration Date <br />❑ San Joaquin County Sheriff -Coroner Explosives Application and Permit <br />License Number Expiration Date <br />❑ California Occupational Safety Health - Blaster <br />License Number Expiration Date <br />REASON FOR DESTRUCTION ❑ Dry ❑ Replacement Well ❑ Caved In ❑ Pit Well Inactive ❑ Test Hole <br />Detected/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 <br />Well Log copy attached ❑ Yes )<, No Grout Seal ❑ No ❑ Yes <br />It below ground surface (bgs) Hole Diameter _ inches <br />Well Conductor Casing ❑ Yes X No Depth of Conductor Casing <br />It bgs Diameter of Conductor Casing inches <br />Well Casing Diameter Ir —inches Total Depth —4b --ft Depth to Water It Depth of Casing It bgs <br />DESTRUCTION SPECIFICATION <br />Sealing Material from ft bgs to _ ft bgs Filler Material <br />from ft bgs to ft bgs <br />Well casing to be perforated by one of the following methods: _ <br />-- from ft bgs to It bgs <br />❑ Mills Knife Number of cuts every ft and/or <br />❑ Explosives ❑ Detonating cord ❑ with projectiles every <br />ft ❑ without projectile <br />❑ Detonating cord and boosters ❑ with projectiles every <br />ft ❑ without projectile <br />❑ Other <br />Sealing Material Neat Cement (94 Ib bag/5-6 gal water) Sand Cement <br />sack mix/7 gal water Bentonite Pellets <br />Bentonite (20% solids) Manufacturer Spec % solids % Name _ <br />Specs on File \ Specs Submitted <br />Placement Method Pumped 'V Free Fall <br />Other <br />Seal Completion D( Complete with Mushroom Cap 7� — S It bgs <br />Complete to Existing Surface Pad <br />I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br />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 />MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br />K <br />4 � i <br />' l <br />CONTRACTORS SIGNATURE ( Ly l &4e-t„�t,✓J, TITLE L I- �k^ `^ DATE' <br />9 D P A R T M E N T USE O N Y <br />Application Accepted BAJADate <br />Destruction Inspection By dJt, Date <br />COMMENTS CO 00 43320 b Zo/ l <br />Area �G✓7 <br />Employee ID# <br />PE <br />SC <br />Info <br />Received <br />B <br />Check#/ <br />Cash <br />Amount <br />Remitted <br />Date <br />Permit/Codes <br />Service Request # <br />Invoice # <br />Well ID# <br />3 <br />�3 <br />lb <br />00 -7 ?S <br />01 V0 03 1U°I <br />EHD 43-08 WELL DESTRUCTION PERMIT <br />4/30/12 <br />