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WELL DESTRUCTION PERMIT P,./ PUBLIC WATER SYSTEM ❑ Yes 0 No SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 East Hazelton Avenue - STOCKTON CA 95205 - (209) 468-3420 NON-REFUNDABLE PERMIT CALL (2091953-76517 FnR INgPFrTInNC FXPIPFS 1 YEAR FFRnM I)eTr= ICCI IFn JOB ADDRESS LJ q � 7 PJ IQ P y rr; CITY/ZIP LG Cl . CROSS STREET h Gin APN OS S-�cS G - 2 PARCEL SIZE /LAND USE APPLICATION # OWNERR., 11 Kf M; IV me Ai'i Q TY PHONE Date 4' OWNER ADDRESS + W N w 12- CITY/STATE/ZIP IG 6/;/ n L : C ,A 64S.2 V 2 - G CONTRACTOR -Z j�'� PHONE 7�6 /— -322-3'12-0 CONTRACTOR y�j'lt� CONTRACTOR ADDRESS / t' - / / �b CITY/STATE/ZIP / / o� 7L — Zi C-57 WELL DRILLING LICENSE NUMBER O ~ v ( EXPIRATION DATE G O PERFORATION CONTRACTOR PHONE 11 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 ❑ 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 _ Well Log copy attached ❑ Yes ❑ No Grout Seal ❑ No ❑ Yes It below ground surface (bgs) Hole Diameter inches Well Conductor Casing ❑ Yes ❑ No Depth of Conductor Casing _ 3V& ft bgs Diameter of Conductor Casing inches Well Casing Diameter_ inches Total Depth r_—ft Depth to Water 2 2- ft Depth of Casing_ �� ," ft bgs DESTRUCTION SPECIFICATION "�� ?� Sealing Material from ft bgs to ft bgs Filler Materialy� from ft bgs to l 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 ft 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 mix17 gal water Bentonite Pellets Bentonite (20% solids) Manufacturer Spe % solids_ _% Name Specs on File Specs Submitted Placement Method Pumped Free Fall n Other Seal Completion 4✓ 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, 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. MIN)AAYM, P24 ,OUR ADVANCE NOTICE REQUIRED FOUR INSPECTIONS �✓ CONTRACTORS SIGNATURE TITLE "� ' -"'/ DATE 1�1 Application Accepted By _ t Destruction Inspection By COMMENTS C h G be CU iA.) e D PARTMENT USE ONL Received Date Amount Date 4' C'n.\ C r:, v hol Area Z Employee ID# U L'), 11 /49 S 4t, l, c 4 PE Sc Received Check#/ Amount Date Permit/ Invoice # Well ID# Codes Info By Cash Remitted 11 Service Request # y3 I b01?8 'wa2s' /d EHD43-08 WELL DESTRUCTION PERMIT 4/30/12