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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 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS T ! ^ 6 4C;ACJ (7„�CL y.- <br />C I <br />CITY/ZTPA <br />ZP <br />CROSS STREET 4 A- APN -Z(f7 <br />p- <br />"r] � PARCEL SIZE�`t)'4AND USE APPLICATION _ <br />At <br />OWNER I QC Lo iJCLo <br />PHONE %5 O 66rqc'3!Z <br />OWNERADDRESS -�'-�S2 Ci'Clr<-L✓C`- ' (✓C <br />Jc/ <br />.�-r- <br />TE//L/C4r-Q4C►�CdpaS\C� <br />J <br />CONTRACTOR C � <br />-rm&5KWE Z09 ry— 6 6 Z <br />CONTRACTOR ADDRESS 7,6C <br />CITYISTATEf7lP0.6*, 7-5-501 <br />C-57 WELL DRILLING LICENSE NUMBER[6 2 73 <br />�CLA <br />� <br />2, EXPIRATION DATE / ✓� bl.� �i�J <br />PERFORATION CONTRACTOR <br />PHONE I <br />PERFORATION CONTRACTOR ADDRESS <br />CITYISTATE/ZIP <br />❑ C-57 Well Drilling <br />License Number Expiration Date <br />Bureau of Alcohol. Tobacco and Firearms - Users of High Explosives License Number Expiration Date <br />CHP Hazardous Material Transportation for Explosives <br />License Number Expiration Date <br />San Joaquin County Sheriff -Coroner Explosives Application <br />and Permit License Number Expiration Date <br />California Occupational Safety Health - Blaster <br />License Number Expiration Date <br />REASON FOR DESTRUCTION ❑ Dry ❑ Replacement Well <br />❑ Caved in ❑ Pit Well ❑ Inactive Test Hole <br />Detected / Suspected Well Water Contaminant's) <br />Adjacent property with contamination (Address) <br />Known Soil / Water contaminants at adjacent properly <br />EXISTING WELL CONSTRUCTION DETAILS ❑ Open Bottom <br />y <br />❑ Gravel rack 11Uf1C.7sed X Other %ter 144 lei <br />Well Log copy attached ❑ Yes ❑ No Grout Seal ❑ No <br />❑ Yes -_ ft below ground surface (bgs) Hole Diameter _ Inches <br />Well Conductor Casing ❑ Yes ❑ No Depth of Conductor Casing ft bgs Diameter of Conductor Casing inches <br />Well Casing Diameter nc7es Total Depth <br />ft Depth to Water It Depth of Casing ft bgs <br />14SI7Rr-c-n0l SPFCIFiCATION <br />Q <br />3 S �< <br />Sealing Material hom ftbgs to 4%Z 1brsR-Ugs Filler <br />Malarial t! z-z-t_a'+_�T from h bgs to _ _ It bgs <br />Well casing to be perforated by one of the following methods: <br />_ from h bgs to _ it bgs <br />❑ Mills Knife Number of cuts every <br />ft and / or <br />❑ Explosives ❑ Detonating cord ❑ with projectiles every ft ❑ vathout projectile <br />❑ Detonating cord and boosters ❑ with projectiles <br />every _ R ❑ without projectile <br />❑ Other <br />Sealing Material Neat Cement (94 to Dag / 5-6 gal water) <br />Sand Cement Sack mix / 7 gal water Bentonite Pellets <br />Bentonite (20% solids) Manufacturer Spec % solids_ <br />% Name Specs on File Specs Submitted <br />Placement Method Pumpetl Free Fall <br />Other <br />Seal Completion Complete with ushroom Cap <br />ft bgs 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 />IN�Ij� IMJ ` '4 HOU�2 ADV N E NOTICE REQUIRED FOUR INSPECTIONS <br />CONTRACTORS SIGNATURE l/(///�L . f TITLE DATE-- _ 2 7 — Iff <br />Application Accepted By _ <br />Destruction Inspection By <br />COMMENTS <br />qR <br />f '4 9 ?018 <br />IN 'opp�roH�' <br />SENT <br />N5c-k L(LTe- d <br />EP QTMENT USE ON6Y <br />Date l Area— <br />Date Employee IDp <br />PE SC Received hoc Amount Penhitl <br />Codes Info alt emitted Date Service Request IY Invoice 0 Well ID# <br />EHD 43-M <br />1015/07 <br />WELL DESTRUCTION PERMIT <br />