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WELL DESTRUCTION PERMIT PUBLIC WATER SYSTEM ❑ Yes [q No SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 East Hazelton Avenue - STOCKTON CA 95205 - (209) 468-3420 NOMI-RFFI INnARl F PFRMIT CAI I (90CA A53-76017 Fnn INSPFCTInN3 EXPIRES 1 YEAR FROM DATE ISSUED nJOB ADDRESS l / ,pM fi ' v 1 no Luc c, ITYlZip Lt n �e ( G, J6 ;6 " CROSS STREET C /` APN �-�.� r Sly N7 &4_ PARCEL SIZEO ' LAND USE APPLICA IO # /J OWNER 1 RO1J PHONE / S� 7 % S � FCC OWNER ADDRESS ,B/r CITY/STATE/ZIP r. i •s CONTRACTOR L. < < .l G PHONE76 �6 y, CONTRACTOR ADDRESS J O O 1 p CITY/STATE/ZIP / d/ G c C I� / C,:2,fC Hd C-57 WELL DRILLING LICENSE NUMBER Y 3 y EXPIRATION DATE S— 3 / f 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 Well ❑ Caved In ❑ Pit Well Z -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 P V C Well Log copy attached ❑ Yes ❑ No Grout Seal ❑ No lg Yes S_ 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 ILI inches Total Depth f ;9 6o It Depth to Water s/ It Depth of Casing ft bgs DESTRUCTION SPECIFICATION Sealing Material from /.y(u It bgs to _ ft bgs Filler Material_ from ____ _ ______ft bgs to ft bgs Well casing to be perforated by one of the following methods: __ __ ____ __from - ft bgs to_ _ It 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 It ❑ without projectile ❑ Other Sealing Material Neat Cement (94 Ib bag/5-6 gal water) A Sand Cement /0, 3 sack mix/7 gal water i Bentonite Pellets Bentonite (20% solids) Manufacturer Spec % solids % Name Specs on File Specs Submitted Placement Method c_� Pumped Free Fall Other Seal Completion t ---Complete with Mushroom Cap _S_ _ 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. JAN ® 4 a SqN ,/ >r OAQU/N N� l opNM NrA r T m C C A ARTMENT USE ONLY � )Mari �if'ti Application Accepted By _ Date I - Y Area /� Destruction Inspection By Date Zl1l Employee ID# A h r✓1 r G1 . COMMENTS Ar)0ravf Ur SQa 1;no1 t r\Sfem 0 t nF♦ fGrofir (PVC PE Codes Sc Info Received Bv Check#/ CTSM Amount Remitted Date Permit/ Service Request # Invoice # Well ID# 411-1 IbS �"7 1-1-1 IAA _Z-Mbi EHD 43-08 WELL DESTRUCTION PERMIT 4/30/12