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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-REFUNDABLE PERMIT CALL (9091 953-7897 FnR INSPF(:TInNR FXPIPFC I VFAR FQnee nATc ICQI ICn JOB ADDRESS ZI -7 d hC T I C CITY/ZIP C—G � ^ 2-17 ! j l CROSS STREET Pe 1 � I -e r APN d 17 - /SU - L43 PARCEL SIZE- 6 Z/LAND USE APPLICATION # OWNER c�v�y Te�rS 1 Ci PHONE 6 Q�'Sbs 1 ' OWNER ADDRESS t' V, C/'C CITY/STATE/ZIP v- o '257220 CONTRACTOR MA -Cl Jf Dr ►N 11 \ 14 J:1 C , PHONE 2217—/ -1 CONTRACTOR ADDRESS 119 A Ih ens [2 4 CCITY/STATE/ZIPN IP / OJ- 44 /_ ` >j C-57 WELL DRILLING LICENSE NUMBER &6186�1i ) EXPIRATION DATE 14-361 C1 PERFORATION CONTRACTOR PHONE 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 )4 Dry Replacement Well ❑ Caved 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 It bgs Diameter of Conductor Casing inches Well Casing Diameter_, _ inches Total Depth -2 It Depth to Water ,C _ It Depth of Casing i ft bgs DESTRUCTION SPECIFICATION Sealing Material from :70 ft bgs to �� It bgs Filler Material ► from _ It bgs to ft bgs Well casing to be perforated by one of the following methods: from ft bgs to ft bgs ❑ Mills Knife Number of cuts every It and/or ❑ Explosives ❑ Detonating cord ❑ with projectiles every ft ❑ without projectile ❑ Detonating cord and boosters ❑ with projectiles every ft ❑ without projectile ❑ Other Sealing Material Neat Cement (941b bag/5-6gal water) i Sand Cement sack mix17 gal water Bentonite Pellets �Bentonite (20% solids) Manufacturer Spec % solids % Name Specs on File Specs Submitted Ia<cement Method � Pumped Free Fall Other Seal Completion Complete with Mushroom Cap Z ft 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. MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS CONTRACTORS SIGNATURE c-yJ� TITLE /l)rtlllCl DATE q- / PARTMENT Application Accepted By Destruction Inspection By COMMENTS O N L Y Employee ID# v)611!X PE Codes Sc Info ReceivedChec B as Amount Remitted Date Permit/ Service Request # Invoice # Well ID# y36j( o 3 I2zN7 w6bot)�l EHD 43-08 WELL DESTRUCTION PERMIT 4/30/12