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WELL DESTRUCTION PERMIT "'0'14 PUBLIC WATER SYSTEM ❑ Yes ❑ No SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 East Hazelton Avenue - STOCKTON CA 95205 - (209) 468-3420 NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS X Jpq 1^� CITY/ZIP Received B p CROSS STREET _ APN 0 t % D U %Z PARCEL SIZEI �• � LAND USE APPLICATION # ,,QAA OWNER � ,VI PHONE Permit/ Service Request # OWNER ADDRESS CITY/STATE/ZIP CAA - CONTRACTOR 1L PHONE Z CONTRACTOR ADDRESS CITY/STATE/ZIP 5 C-57 WELL DRILLING LICENSE NUMBER EXPIRATION DATE r% /1 PERFORATION CONTRACTOR PHONE PERFORATION CONTRACTOR ADDRESS CITY/STATE/ZIP r �l +� -0 C-57 Well Drilling License Number ExpirationDate IV >n ❑ Bureau of Alcohol, Tobacco and Firearms - Users of High Explosives ❑ CHP Hazardous Material Transportation for Explosives License Number License Number Expiratiola m Expi tion Date ❑ San Joaquin County Sheriff -Coroner Explosives Application and Permit License Number Expira t ElCalifornia Occupational Safety Health - Blaster License Number IP �/v71' REASON FOR DESTRUCTION ❑ Dry ❑ Replacement Well ❑ Caved In ❑ Pit Well , Inactive ❑Test I EN7 Detected/Suspected Well Water Contaminant(s)yzp e _ Adjacent property with contamination (Address) Known Soil/Water contaminants at adjacent property _ EXISTING WELL CONSTRUCTION DETAILS 41 Open Bottom ❑ Gravel Pack ❑ Uncased ❑ Other Well Log copy attached ❑ Yes t# No Grout Seal ❑ No ❑ Yes _ _ ft below ground surface (bgs) Hole Diameter inches Well Conductor Casing ❑ Yes No Depth of Conductor Casing _ _...__._it bgs Diameter of Conductor Casing -- inches Well Casing Diameter _R, —inches Total Depth It Depth to Water_ _ ft Depth of Casing ` It bgs DESTRUCTION SPECIFICATION ^^ nn Sealing Material from _oft bgs to It bgs Filler Material �— _ from -----1t bgs to ._ft bgs Well casing to be perforated by one of the following Il ethods: from It bgs to_ ft bgs ❑ Mills Kni Numb r of cuts every ft andel ❑ Explosive ❑ Detonating cord ❑ with projectiles every ft ❑ w out projectile Detonating cord and oosters ❑ with projectiles every f� ❑ with rojectile ❑ Other Sealing Material Neat Cement (94 lb bag/5-6 gal water) Sand Cement sack mixll gal water Bentonite Pellets Be„tonitE (2041. solids) Manufacturer Spec % solids % Name __ Specs on File Specs Subrnitted Placement Method 1 Pumped * Free Fall F' Other Seal Completion & Complete with Mushroom Cap JL_. ft 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. MI M 24 HO�U%R% ADVANCE NOTICE REQUIRED FOR INSPECTIONS p CONTRACTORS SIGNATURE / �/ �� TITLE DATE 0 14 19 ,�J 0 J J 6 o'A) t° r,1 'dam 71 r� PE Codes 9C Info Received B hec ash Amount Remitted Date Permit/ Service Request # _ Invoice # — Well ID# FWd'r lr / Application Accepted By Destruction Inspection By COMMENTS M 1 _ DEPARTMENT USE 4 DateO ___ Date f ON LY r/ ti 3 i L Area Employee ID# U n � �' I b r �l +� T Vv PE Codes 9C Info Received B hec ash Amount Remitted Date Permit/ Service Request # _ Invoice # — Well ID# EHD 43-08 WELL DESTRUCTION PERMIT 4/30/12