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WELL DESTRUCTION PERMIT � PUBLIC WATER SYSTEM ❑ Yes ❑ No SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 East Hazelton Avenue - STOCKTON CA 95205 - (209) 468-3420 NON-REFIINDARI F PERMIT CALL (209) 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS ��N _ CITY/ZIP oK I Z;f CROSS STREET �19/lZCJ�t �_ APN e !;e 9 Z Z&,o 3 PARCEL SIZE �ND USE APPLICATION # OWNER_ � �(// V �� PHONE OWNER ADDRESS!/lJ 0� ;¢ /` --- /� 9�� CITY/STATE/ZIP "V e l , o CONTRACTOR1,___ _PHONE CONTRACTOR ADDRESS d . IOo 'W- jig CITY/STATE/ZIP L b?.LJ L If C-57 WELL DRILLING LICENSE NUMBER 1J ! �J r Z _ EXPIRATION DATE /O f5 PERFORATION CONTRACTOR PHONE 327 -3 f z e) 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 Ja Dry ❑ Replacement Well fid—Gaved 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 ft bgs Diameter of Conductor Casing inches Well Casing Diameter_t(:)" inches Total Depth It Depth to Water 411;i_ It Depth of Casing - - _ It bgs DESTRUCTION SPECIFICATION Sealing Material from ft bgs to _. _ ..___ _ _. It bgs Filler Material er�2,e4_t - from _ ft bgs to ft bgs Well casing to be perforated by one of the following methods: _ _ from It bgs to---- - ft bgs ❑ Mills Knife NUrnber of cuts every ___ft and/or ❑ Explosives ❑ Detonating cord ❑ with projectiles every _ It ❑ without projectile ❑ Detonating cord and boosters ❑ with projectiles every . It ❑ without projectile ❑ Other—_..— Sealing Material Neat Cement (94 Ib bag15-6 gal water)*_ Sand Cement 0_ , _ 3 _ sack mix,7 gal water Bentonite Pellets Bentonite (20% solids) Manufacturer Spec % solids _ " o Name.----------. Specs on File Specs Submitted Placement Method Pumped Free Fall Other Seal Completion Complete with Mushroom Cap It 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. MAIN 24 HOUR ADVANCE NOTICE REQUIRED FOR I / TIONS CONTRACTORS SIGNATURE //��" ' TITLE [01171 -s4 DATE 3 ` 2 �IJ v� � ��rtsw•"� jlc �e P �La * 4� � � EP,�RT��NT dw EPARTMENT USE ONLQ� Application Accepted By _ Date O CJ Area `C"( Destruction Inspection By _ Date Employee ID# COMMENTS _ PE Codes SC Info ReceivedC B ek ash Amount Remitted Date Permit/ Service Request # Invoice # Well ID# � W 13M i'405 � EHD 43-08 WELL DESTRUCTION PERMIT 4/30/12