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WELL DESTRUCTION PERMIT P ✓ PUBLIC WATER SYSTEM ❑Yes4Q No SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 East Hazelton Avenue-STOCKTON CA 95205 - (209)4668-3420 NON-REFUNDABLE PERMIT CALL 209 9p3-7697 FOR INSPECTIONS EXPIRES EXPIRES 11 YEAR FROM DATE ISSUED JOB ADDRESS U e A LA, 41 CITY/ZIP 4�'r K��(�: 7��3� 41 Tim l2 l�!�r f /� a CROSS STREET J /� APN 2�1' /,dD - t 2* PARCEL SIIZELAND USE APPLICATION# OWNER r ,t VvXel'SOr 1 PHONE !VR 3' ��I � f7 f OWNER ADDRESS S Ur' H U CITY/STATE/ZIP Aq('l r' 't cc, CONTRACTOR S P h t PHONE c 4 CONTRACTOR ADDRESSAlk /S CITY/STATE/ZIP- L1 ✓�✓ I �. C-57 WELL DRILLING LICENSE NUMBER EXPIRATION DATE - PERFORATION CONTRACTOR PHONE PERFORATION CONTRACTOR ADDRESS CITY/STATE/ZIP ❑ 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 DryReplacement Well ❑ Caved In [IPit Well ❑ Inactive E] 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 'W—inches Well Conductor Casing ❑ Yes ❑ No Depth of Conductor Casing It bgs Diameter of Conductor Casing inches Well Casing Diameter_inches Total Depth ft Depth to Water (' r2__ft Depth of Casing J " It bgs DESTRUCTION SPECIFICATION Sealing Material from -__ft bgs to ft bgs Filler Material 13-e +v, 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_ It 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 lb bag/5-6 gal water) Sand Cement sack mix/7 gal water Bentonite Pellets x Bentonite(20%solids) Manufacturer Spec%solids—% Name Specs on File Specs Submitted Placement Method X Pumped - Free Fall Other Seal Completion)� Complete with Mushroom Cap 2 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. MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS CONTRACTORS SIGNATURE c�ei�T '� TITLE A-1 11V-- DATE I _-1_ ...._- ..-- .. ._........... ............ .... . . .. .. _ � �j4 _... ..... ,1 �..... _._I ...._ _..._ Sa 3 c��VFCB ,v _..__. R 17 ..........; ! .. ._. _._.......... _ ....._.._ ._ , • ......_ _....... -. . �.._. ...... .. _ SAN 2018 NEq RO NOUAlry - - C�$ EPARTM M I` ��- _�- .. . ._. __._:. - - - --- i t i DEPARTMENT USE ONLY 9 Application Accepted By7� _ Date -� Area Destruction Inspection By Date `Y Employee ID# A COMMENTS PE SC Received Chec Amount D to Permit/ Invoice# Well ID# Codes Info B sh Remitted Service Re uest# q3� W1 06,& P06DB1 5 EHD 43-08 WELL DESTRUCTION PERMIT 4/30/12