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WELL DESTRUCTION PERMrr � 31- 32i 0 P/ R-" <br />PUBLIC WATER SYSTEM ❑ Yes ❑ No <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALIH DEPARTMENT 1868 East Hazelton Avenue - STOCKTON CA 95205 - (209) 468-3420 <br />NON-REFUNDABLE PERMIT CALL (209) 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS <br />CITY/ZIP �/�/V 9 574-19 <br />//�� <br />- /� O +� <br />CROSS STREET APN <br />�'7J <br />PARCEL SIZO-2-11D USE APPPLLICA�TI/ON # <br />- <br />OWNER `/ � 'I//J� /1l �/ / <br />PHONE <br />OWNER ADDRESS <br />CITY/STATE/ZIP `JK1,rL/t <br />CONTRACTOR �, - HONE �!'% L / j�' � U <br />r <br />CONTRACTOR ADDRESSlzz <br />CrrY/STATERIP <br />❑ C-57 WELL DRILLING LICENSE NUMBER <br />EXPIRATION DATE �(> <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 Contarnmant(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 Cf Yes <br />_._ It below ground surface (bgs) Hole Diameter _----- inches <br />Well Conductor Casing ❑ Yes ❑ No Depth of Conductor Casing _. _- _ _ <br />.__ It bgs Diameter of Conductor Casing inches <br />_ <br />Well Casing Diameter__inches Total Depth 1-06- .. It Depth to Water It Depth of Casing It bgs <br />DESTRUCTION SPECIFICATION <br />Sealing Material from---d�2-_ ft bgs to �ft bgs Filler Material _. <br />_ from ft bgs to It bgs <br />Well casing to be perforated by one of the following methods: _ <br />--from _. _ ft bgs to---- ft 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 />It ❑ without projectile <br />❑ Other <br />Sealing Material Neat Cement (94 lb bag/5-6 gal water) Sand Cement <br />sack mix17 gal water -JO Bentonite Pellets <br />Bentonite (20% solids) Manufacturer Spec % solids ___- __ 4o Name--, <br />___ _________ Specs on File Specs Submitted <br />Placement Method Pumped oW Free Fall <br />Other <br />Seal Completion Complete with Mushroom Cap ft bgs I. -Y 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 />CONTRACTORS SIGNA <br />HO ANCCEE/NOTICE REQUIRED FOR INSPECTIONS / J <br />TITLE �C DATE 7LCWS <br />3 { <br />0.E ARTMENT USE ON Y d <br />/�Application Accepted By _ - ___ -- -_ -- _-___ . . _ Dale - `� Z��_ AreaL14-- -._—_ <br />Destruction Inspection By / Employee IDft_ <br />Liv ���----m�--- - - Date._ /l�Z4l� <br />COMMENTS Grokw-'r � s -- t� . <br />f.+On H'e Ce, -e. . nom. X U. f e j - - - o i 0-41 t"F1t* . <br />PE <br />SC <br />Received <br />Amount <br />Date <br />PermiU <br />Invoice # <br />Well ID# <br />Codes <br />Info <br />Cash <br />Remitted <br />Service Request # <br />ffJ <br />0 <br />-- ---7 <br />% <br />_ <br />fin OO 3-2 <br />EHD 43-08 WELL DESTRUCTION PERMIT <br />4/30/12 <br />