Laserfiche WebLink
WELL DESTRUCTION PERMIT <br />Pf <br />PUBLIC WATER SYS LEM ❑ Yes KNo <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 INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS 19 < Z//,, <br />CITY/ZIP /'{�-LJ'Cpi <br />/ <br />CROSS STREET G `� 'A APN ` ' I V <br />PARCEL SIZE G' LAND USE APPLICATION # <br />1 <br />OWNER .} U U A iC C C1 <br />PHONE <br />,tU 1 1 n } e r <br />OWNER ADDRESS V �/' <br />CITY/STATE/ZIP ! 1 G) ✓'I lig C 4( f 5 J <br />,_,c <br />CONTRACTOR G I</K! % <br />PHONE <br />CONTRACTOR ADDRESS / d ' " d / <br />CITYCITY/STATE/ZIPaD <br />�7 <br />�- C-57 WELL DRILLING LICENSE NUMBGt�G ER 'p -I Z� I G� -3 <br />EXPIRATION DATE�Z -!3/— Ar <br />PERFORATION CONTRACTOR <br />a <br />PHONE 3z7- 7120 <br />PERFORATION CONTRACTOR ADDRESS <br />p <br />CITY/STATE2IP <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 Pennit <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 V Open Bottom ❑ Gravel Pack ❑ Uncased ❑ Other <br />Well Log copy attached ❑ Yes ❑ No Grout Seal ❑ No ❑ Yes <br />ft 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 />Well Casing Diameterinches Total Depth Ifl_ft Depth to Water g It Depth of Casing It bgs <br />DESTRUCTION SPECIFICATION <br />Sealing Material from 1/10 ft bgs to -3 ft bgs Filler Material Liz from It bgs to _—ft bgs <br />Well casing to be perforated by one of the following methods: <br />from It 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 />ft ❑ without projectile <br />❑ Other <br />Sealing Material Neat Cement (94 lb bag/5-6 gal water) i i Sand Cement <br />sack mix/7 gal water v� Bentonite Pellets <br />Bentonite (20% solids) Manufacturer Spec % solids____ __ % Name <br />- _ Specs on File Specs Submitted <br />Placement Method Pumped Ar- Free Fall n <br />Other <br />Seal Completion X Complete with Mushroom Cap 3 ft 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 />� <br />UM <br />244HHOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br />CONTRACTORS SIGNATURE^ TITLE DATE /Z <br />m <br />_ EPARTMENT USE ONLY <br />Application Accepted By Date <br />Area / ' ► C1 ti � <br />Destruction Inspection By iiar? Date 2- _ �� Employee ID# Ahmr <br />COMMENTS <br />z <br />PE <br />Codes <br />SC Received <br />Info B <br />Ch Amount Dat Permit/ <br />ash Remitted Service Re uest # <br />Invoice # <br />Well ID# <br />OP 3 <br />16 i <br />I bq i � 0 <br />EHD 43-08 WELL DESTRUCTION PERMIT <br />4/30/12 <br />