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WELL DESTRUCTION PERMIT <br />P BLIC WATER SYSTEM ❑ Yes o <br />ot-�• �% %fes Gly-,�i�� ' _ ' �j_ <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 East Hazelton Avenue - STOCKTON CA 95205 - (209) 468-3420 <br />NON-REFUNDABLE PERMIT CALL (2091 953-7697 Fr)R INSPFCTIONS FXPIRFS 1 YFAR Fanlu DATE IccIIFn <br />JOB ADDRESS <br />CITY/ZIP <br />CROSS STREET APN -OR <br />PARCEL SIZE& LAND USE APPLICATION # <br />OWNER VPHONE <br />( ® 15 ZI$040 <br />OWNER ADDRESS 12;CITY/STATE/Z <br />IP <br />CONTRACTOR / _'—! PHONE Fly 6 ZLn <br />CONTRACTOR ADDRESS 7-12-1LQ <br />CITY/STATE/ZIP <br />pp <br />C-57 WELL DRILLING LICENSE NUMBER <br />EXPIRATION EXPIRATION DATE <br />PERFORATION CONTRACTOR T1 <br />PHONE <br />PERFORATION CONTRACTOR ADDRESS <br />CITY/STATE/ZIP <br />❑ C-57 Well Drilling <br />License Number Expiration Date <br />❑ Bureau of Alcohol, Tobacco and Firearms - Users of High Explosives <br />License Number Expiratio$% <br />❑ CHP Hazardous Material Transportation for Explosives <br />License Number Expirat' � , <br />❑ San Joaquin County Sheriff -Coroner Explosives Application and Permit <br />License Number Expiration DaTeCt vcn <br />❑ California Occupational Safety Health - Blaster <br />License Number ExpiraMAVatq <br />REASON FOR DESTRUCTION Oery JWReplacement Well ❑ Caved In ❑ Pit Well ❑ Inactiv ❑ TsteH <br />����'gQUfN <br />Detected/Suspected Well Water Contaminant(s) <br />Adjacent property with contamination (Address) <br />IT <br />HEALrw ENTAL <br />Known Soil/Water contaminants at adjacent property__ <br />___rMENT <br />EXISTING WELL CONSTRUCTION DETAILS ❑ Open Bottom ❑ Gravel Pack ❑ 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 Dep���ff C``oDductor Casing <br />ft bgs Diamet r of Conductor Casing _ _. inches <br />Well Casing Diameterle inches ToiIP epth//KK_ tt Depth to <br />Water_ It t oCasing ._ _ ..__ ft bgs <br />DESTRUCTION SPECIFICATION <br />Sealing Material from ft bgs to _ ft bgs Filler Material <br />_ _ -- _ from __ ft 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 ft 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 Ib bag/5-6 gal water) Sand Cement <br />_sack mix/7 gal water l/ Bentonite Pellets <br />Bentonite (20% solids) Manufacturer Spec % solids % Name-- <br />__ __ __ Specs on File Specs Submitted <br />Placement Method Pumped X Free F4 <br />Other <br />Seal Completion �% Complete with Mushroom Cap . _74i bgs <br />Complete to Existing Surface Pad e::���C <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 />R ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br />CONTRACTORS SIGNATURE TITLE Di�%i'f�L DATE�� <br />D E A R T M E N T USE O N I Y <br />Application Accepted By __. Dale �_Area _ <br />Destruction Inspection By n _ Date__ 2�/ Employee ID# <br />COMMENTS <br />PE <br />Codes <br />Sc <br />Info <br />Received <br />B <br />hec <br />ash <br />Amount <br />emitte <br />Dat <br />PermiU <br />Service Request # <br />Invoice # <br />Well ID# <br />LS� <br />18 <br />WPOD3PA3 2_5 <br />EHD 43-08 WELL DESTRUCTION PERMIT <br />4/30/12 <br />T <br />