Laserfiche WebLink
WELL DESTRUCTION PERMIT <br />PUBLIC WATER SYSTEM ❑ Yes ❑ No <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPT 1868 East Hazelton Avenue - STOCKTON CA 95205-6232 - (209) 468-3420 <br />NON-REFUNDABLE PERMIT CALL 12091953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS A A " <br />CITY/7JP <br />T�241 1W <br />CROSS STREET G1�r�'sfiGr� APN 2 L 3 70 VI) <br />PARCEL S-ZULAND IISE APPLICATION # <br />OWNER er, 12 <br />PHONE <br />OWNER ADDRESS d CITY/STATE21P�itt� <br />7 - �n'L4ZC <br />CONTRACTOR j'r/ S1t6 6"" re/ 6 /;/ OlN <br />I PHONE <br />CONTRACTOR ADDRESS I d [ <br />CITY/STATE21P <br />- / <br />C-57 WELL DRILLING LICENSE NUMBER b <br />EXPIRATION DATE <br />PERFORATION CONTRACTOR <br />PHONE <br />PERFORATION CONTRACTOR ADDRESS <br />CITYISTATE/7iP <br />C-57 Well Drilling <br />License Number <br />Expiration Date <br />Bureau of Alcohol, Tobacco and Firearms - Users of High Explosives <br />License Number <br />Expiration Date <br />CHP Hazardous Material Transportation for Explosives <br />License Number <br />Expiration Date <br />San Joaquin County Sheriff -Coroner Explosives Application and Permit <br />License Number <br />Expiration Date <br />California Occupational Safety Health - Blaster <br />License Number <br />Expiration Date <br />REASON FOR DESTRUCTION Dry ❑ Replacement Well ❑ Caved In ❑ Pit Well <br />❑ Inactive ❑ Test Hole <br />Detected / Suspected Well Water Contaminants) <br />Adjacent property with contamination (Address) <br />Known Soil /Water contaminants at adjacent property <br />EXISTING WELL CONSTRUCTION DETAILS ❑ Open Bottom ❑ Gravel Pack ❑ <br />Uncased ❑ Other <br />Well Log copy attached ❑ Yes ❑ No Grout Seal ❑ No ❑ Yes <br />ft below ground surface (bgs) Hole Diameter inches <br />Well Conductor Casing ❑ Yes ❑ No Depth of Conductor Casing <br />ft bgs Diameter of Conductor Casing Inches <br />Well Casing Diameter inches Total Depth ft Depth to Water ft <br />Depth of Casing ft bgs <br />DESTRUCTION SPECQFTCATIO <br />Sealing Material from ft bgs to � ft bgs Filler Material <br />from ft bgs to ft bgs <br />Well casing to be Derfora d by one of the following methods: <br />from <br />ft bgs to ft bgs <br />❑ Mills Knife Number of cuts every ft and / or <br />❑ Explosives ❑ Detonating cord ❑ with projectiles every <br />ft <br />❑ without projectile <br />❑ Detonating cord and boosters ❑ with projectiles every <br />ft <br />❑ without projectile <br />❑ Other <br />bag /5-6gal water) Sand Cement sack mix/7 gal water Bentonite Pellets <br />Sealin �I�I —�C.mplelevA <br />Bentonite (20%cturer Spec % solids _% Name <br />Specs on File Specs Submitted <br />Placement a to Free Fall <br />Other <br />Seal Completion room Cap ft bgs <br />Complete to Existing Surface Pad <br />00 <br />d <br />N <br />I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br />JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br />CURRENT AND ACTIVE WITH THIP CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br />WORKERS COMPENSATION LAW . <br />MJ OUR CE NOTICE REQUIRED FOR iN/S/PEC/TIONS �J �J <br />CONTRACTORS SIGNATURE TITLE �/�i/L{�/ DATE 6V � / `ZC(�J <br />Application Accepted By - <br />Destruction Inspection By <br />COMMENTS <br />TMENT USE ONLY / <br />Date Area u <br />Date Employee ID#_. <br />PE SC Received a Amount Date Permit/ Invoice# WeIIID# <br />Codes Info By Cash Remitted Service Reguest# <br />"7 k4�rJ I <br />EHD 43-08 <br />10/5/07 <br />WELL DESTRUCTION PERMIT <br />