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WELL DESTRUCTION PERMIT <br />PUBLIC WATER SYSTEM ❑ Yes o <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 East Hazelton Avenue - STOCKTON CA 95205 - (209) 468-3420 <br />NON-REFUNDABLE PERMIT a CALL (209) 953-7697 FOP, INSPECTIONS.. EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS G �-r ' <br />CI YR Z3 <br />M�APN <br />3 <br />GAND <br />CROSS STREET <br />PAZEL SIZE SEPLIC ON # <br />OWNER /(l��/�� <br />PHONE 07 <br />OWNER ADDRESS Z7 / v� %� O <br />�y—� ^44� <br />CITY/STATE/ZIP Spg--7f/ <br />CONTRACTOR /�/� <br />PHONE /_— <br />CONTRACTOR ADDRESS 2 1 -;?o JvC <br />':F <br />CITY/STATE/ZIP_--3PA:- <br />/ C-57 WELL DRILLING LICENSE NUMBER <br />rr,, <br />EXPIRATION DATE C� _ <br />PERFORATION CONTRACTOR <br />PHONE <br />PERFORATION CONTRACTOR ADDRESS <br />CITY/STATE/ZIP <br />❑ C-57 Well Drilling <br />License Number Expiration Date <br />❑ Bureau of Alcohol, Tobacco and Firearms - Users of High Explosives <br />License Number Expiration Date <br />❑ CHP Hazardous Material Transportation for Explosives <br />License Number Expiration Date <br />❑ San Joaquin County Sheriff -Coroner Explosives Application and Permit <br />License Number Expiralisl�QgtAe�Y <br />/Ion <br />❑ California Occupational Safety Health - Blaster <br />License Number Expir <br />REASON FOR DESTRUCTION ❑ DryReplacement Well ❑ Caved In ❑ Pit Well ❑ Inactive <br />Detected/Suspected Well Water Contaminants) _ <br />Adjacent property with contamination (Address) <br />Known Soil/Water contaminants at adjacent property _—_ <br />_ _ SAH JO <br />- _1�-- JOA <br />CC),- <br />NEI <br />EXISTING WELL CONSTRUCTION DETAILS Open Bottom L1 Gravel Pack ❑ Uncased ❑ Other ___ �EPgRTIIq. <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 Dept�ctor Casing <br />114 <br />ft bgs �/� Diameter of Conductor Casing _ inches <br />Well Casing Diameter inches Tota Depth l ..fI Depth to Water Z__ it Depth of Casing — ft bgs <br />DESTRUCTION SPECIFICATION <br />Sealing Material from ft bys to ..... ____ ft bgs Filler Material__ <br />_ _ from _ — it bgs to ft bgs <br />Well casing to be perforated by one of the following methods: <br />--from ft bgs to _.___ It bgs <br />❑ Mills Knife Number of cuts every It and/or <br />❑ Explosives ❑ Detonating cord ❑ with projectiles every <br />ft ❑ without projectile <br />❑ Detonating cord and boosters ❑ with projectiles every <br />ft ❑ without projectile <br />❑ Other <br />Sealing Material Neat Cement (94 lb bag/5-6 gal wafer) Sand Cement _-____ <br />__sack mix/7 gal water J Bentonite Pellets <br />Bentonite (20% solids) Manufacturer Spec % solids___ % Name— <br />___._ _______ _ Specs on File Specs Submitted <br />Placement Method Pumped IV Free Fall <br />Other <br />Seal Completion�d Complete with Mushroom Cap ___Z_ r Ry;Y bys <br />Complete to Existing Surface Pad <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 THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br />WORKERS COMPENSATION LAWS. <br />HOVANCE NOTICE REQUIRED FOR INSPECTIONS <br />CONTRACTORS SIGNATURE = 10 TITLE DATE �Z <br />k•-- GyGe atO <br />/1'J rAF -rte ev­—� <br />IT A R T M E N T U S E O N <br />t <br />Application(ccepted By _Q Date <br />Destruction Inspection By _ j V\Q_ Date_ <br />COMMENTS <br />L i <br />� aoa qp <br />/ --- Area r �-- — <br />—O Employee ID#_ <br />s y -I-)"4/n U2d c.V /I (,u <br />PE <br />Codes <br />SC <br />Info <br />Received <br />B <br />he <br />ash <br />Amount <br />ernitte <br />Date <br />PermiU <br />Service Request # <br />Invoice # <br />Well ID# <br />41 <br />P2_ <br />n <br />EIAD 43-08 WELL DESTRUCTION PERMIT <br />4/30/12 <br />