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' WELL DESTRUC-3 m PERMIT r P✓ PUBLIC WATER SYSTEM ❑ Yes ❑ No SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 East Hazelton Avenue - STOCKTON CA 95205 - (209) 468-3420 NON-RFFIINDARI F PFRMIT CALL (9091953-7697 FOR INSPFCTIONS EXPIRES 1 YEAR FROM DATE [S-RI1ED JOB ADDRESS (� � V CITY/ZIP L/ CROSS STRE A P N PARCEL SIZE .O LAND USE APPLICATION # Dat 8 F7 OWNER '� PHONE 7 j - �4 aid OWNER ADDRESS CICITY/STATE/ZIP`\y� �l ' CONTRACTOR11 ✓ PHONE r L{ 2,�J A , CONTRACTOR ADDRESS K� L �' Y�/V �/ 1C CITY/STATE/ZIP4f7VAJ(� S"tL5 ,J2- C-57 WELL DRILLING LICENSE NUMBER �I EXPIRATION DATE/ 1W ( / 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 ❑ Dry ❑ Replacement' ell ❑ Caved In ❑ Pit Well (;C -Inactive E] Test Hole Detected/Suspected Well Water Contaminant(s) ( — Adjacent property with contamination (Address) _ Known Soil/Water contaminants at adjacent property©tel_ EXISTING WELL CONSTRUCTION DETAILS Open Bottom ❑ Gravel Pack ❑ Uncased ❑ Other _ Well Log copy attached ❑ Yes W' -'No Grout Seal ❑ No ,R -Yes It below ground surface (bgs) Hole Diameter inches Well Conductor CasincYes ❑ No Depth of Conductor Casing 7 it b s Diameter of Conductor Casing inches Well Casing Diameter inches Total Depth _21j' 6� it Depth to Water _ ft Depth of Casing _ ft bgs DESTRUCTION SPECIFICATION Sealing Material from __ _ .ft bgs to _ it bgs Filler Material - 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 it ❑ without projectile ❑ Detonating cord and boosters ❑ with projectiles every _-- _ _ ft ❑ without projectile ❑ other _ Sealing Material Neat Cement (94 Ib bag/5-6 gat water) Sand Cement _ __ __ sack mix17 gal water Bentonite Pellets Bentonite (20% solids) Manufacturer Spec % solids____ ,% Name- Specs on File Specs Submitted Placement Method Pumped Free Fall Other Seal Completion Complete with Mushroom Cap 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, ST CAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS CURRENT AND ACTIVE WITH TH ALI RRNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION LAW MI UM24H R ADVANCE NOTICE REQUIRED FQR INSPECTIONS CONTRACTORS SIGNATURE T11 LE % DATEI f Q- i .I i P YM T ; RECEIE jf""V/ r all, SAN JOAurN c ; u TY ENVIRaNMA E1 HEALTH <)EPAR ME T j L E _ I 1 DEPARTMENT USE ON Y Application Accepted By _ __ __ _ Date Area Destruction Inspection By S�M _ _ Date�Q��/� Employee ID# COMMENTS /V! r PE SC Received Info .Check#/ Ca Amount it ed Dat Permit/Codes Service Request # Invoice # Well ID# xAp' to 1� I Ill 10 POD37401 EHD 43-08 WELL DESTRUCTION PERMIT 4/30/12