Laserfiche WebLink
WELL DESTRUCTION PERMIT <br /> PUBLIC WATER SYSTEM ❑Yes [-]No <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 600 E MAIN STREET-STOCKTON CA 95202 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL(209)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS _ A CITY/ZIP 91 oV j1. CIA Slat, y m <br /> CROSS STREET IQ `! APN 2216 170 PARCEL <br /> CSIZE <br /> LAND USE APPLICATION# <br /> OWNER o f-ptt M . 'In�)I PHONE 1(2 95 9 02-,2— <br /> OWNER <br /> ADDRESS 1 ��� V� y�n Jt CITY/STATE/Z <br /> IP C� <br /> CONTRACTOR S 1 1 PHONE 2015212 . 112-0 <br /> { r <br /> CONTRACTOR ADDRESS 1 ' \ CITY/STATE/ZIP ft �ft,j GA ��f <br /> I/C-57 WELL DRILLING LICENSE NUMBER EXPIRATION DATE L� �/� . 17-01 cl <br /> PERFORATION CONTRACTOR PHONE <br /> PERFORATION CONTRACTOR ADDRESS CITY/STATE/ZIP <br /> ❑ C-57 Well Drilling 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 License Number Expiration Date <br /> ❑ San Joaquin County Sheriff-Coroner Explosives Application and Permit License Number Expiration Date <br /> ❑ California Occupational Safety Health-Blaster License Number Expiration Date <br /> REASON FOR DESTRUCTION Dry ❑ Replacement Well 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 property <br /> EXISTING WELL CONSTRUCTION DETAILS ❑ Open Bottom ❑ Gravel Pack ❑ Uncased ❑ Other <br /> Well Log copy attached ❑ Yes ❑ No Grout Seal ❑ No ❑ 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 Diameteru­ inches Total Depth Mft Depth to Water ft Depth of Casing ft bgs <br /> DESTRUCTION SPECIFICATION <br /> Sealing Material from ft bgs to ft bgs Filler Material from ft bgs to ft bgs <br /> Well casing to be perforated by one of the following methods: from ft bgs to ft bgs <br /> ❑ Mills Knife Number of cuts every ft and/or <br /> ❑ Explosives ❑ Detonating cord ❑ with projectiles everyft ❑ without projectile <br /> ❑ Detonating cord and boosters ❑ with projectiles every ft ❑ without projectile <br /> ❑ Other <br /> Sealii Material Neat Cement(94/b bag/5-6 gal water) Sand Cement sack miw7 gal water Bentonite Pellets <br /> Bentonite(20%sol"ds) _= Manufacturer Spec%solids % Name Specs on File Specs Submitted <br /> Placement Method ZP Pumped Free Fall - Other <br /> Seal Completion Complete with Mushroom Cap 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 /> MINMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br /> CONTRACTORS SIGNATURE TITLE DATE � r <br /> Irr <br /> •( rtill �� ��� %) <br /> -- I - Y <br /> __.. SAN JQAQUIN COUNT <br /> _ - ENVIRONMENTAL <br /> HEALTH DEPARTMENT n <br /> n <br /> EP RTM ENT USE O CO <br /> Application Accepted By Date Area ll// CC®® <br /> Destruction Inspection By. p <br /> 711a <br /> * C Date Iz 2.dL Employee ID#_ <br /> f <br /> CO TS cb �r X a u? z 4/ 2 +1 "6 10 c -S-1,41 r.) /LV <br /> .hp�l�ac v <br /> W <br /> PE SC Received Check#/ Amount Permit/ <br /> Codes Info B Cash em"to Date Service Request# Invoice# Well ID# <br /> 7:5-5-1 -Z� / � 7 <br /> EHD 43-08 WELL DESTRUCTION PERMIT <br /> 10/5/07 <br />