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WELL DESTRUCTION PERMIT P v * PUBLIC WATER SYSTEM ❑ Yes 0 No vJell�1 SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 East Hazelton Avenue - STOCKTON CA 95205 - (209) 468-3420 NON-RFniNDARI_F PFRMIT CALL (2091953-7697 FOR INSPFCTIONS EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS v CITY/ZIPf 'YVI / CROSS STREET I ; r /� 1' \ APN d. L4 I Ll I C) 2- G PARCEL SIZE 0 LAND USE APPLICATION # OWNER L T Y G I 1 G 11 J e C of PHONE OWNER ADDRESS 100 I W, C� 4 P r S� y� /� CITY/STATE/ZIPI�! G1 /� � Cc "1 � CIS?? 7 p/J CONTRACTOR "r' /� (J�� P'� PHONE Y U I Q Lodi A -/ S CONTRACTOR ADDRESS 0 V CITY/STATE/ZIP 40- C-57 WELL DRILLING LICENSE NUMBER �f / L 3 EXPIRATION DATE I Z — 3i- / 5 PERFORATION CONTRACTOR PHONE I Z-7 ✓ 1 Z U PERFORATION CONTRACTOR ADDRESS f— CITY/STATE/ZIP `!' _�z Y1 ❑ 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 [�K Inactive ❑ Test Hole Detected/Suspected Well Water Contaminant(s) Adjacent property with contamination (Address) Known Soil/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 Conductor Casing ft b s Diameter of Conductor Casing inches G Well Casing Diameter_ inches Total Depth l— It Depth to Water_ It Depth of Casing It bgs DESTRUCTION SPECIFICATION Sealing Material from !20 _ft bgs to _� ft bgs Filler Material_ x.. ._ Lk* _ 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 cord ❑ with projectiles every ft ❑ without projectile ❑ Detonating cord and boosters ❑ with projectiles every ft ❑ without projectile ❑ Other Sealing Material Neat Cement (94 Ib bag/5-6 gal water) II Sand Cement x sack mix17 gal water y _Bentonite Pellets Bentonite (20% solids) Manufacturer Spec % solids % Name Specs on File Specs Submitted Placement Method Pumped IG Free Fall Other Seal Completion x Complete with Mushroom Cap It 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. 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. MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS CONTRACTORS SIGNATURE / TITLE 9:: y= DATE / Z —! Application Accepted By - Destruction Inspection By COMMENTS kt4t.12 PARTMENT USE ONLY Liles __ Date 1 �" ^ Date D to Area S l rn G h 4C CIG,I Employee ID# h rn P (l PE Codes Sc Info Received B Cash Amount Remitted D to Permit/ Service Request # Invoice # Well ID# �3 (o► 3a L ©37b5 EHD 43-08 WELL DESTRUCTION PERMIT 4/30/12