WP0037242 - Laserfiche WebLink

Home Browse Search

4 r WELL DESTRUCTION PERMIT PUBLIC WATER SYSTEM ❑Yes 2 No SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPT 1868 East Hazelton Avenue - STOCKTON CA 95205-6232 - (209) 468-3420 NON-REFUNDABLE PERMIT CALL (209) 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED 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 1 AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION LAWS. <-L7 Ii CONTRACTORS CE REQUIRED FOR INSPECTIONS TITLE \J P DATE I `Nt Cyon IL AYMEN DEPARTMENT USE ONLY Application Accepted By Date ` I L ( -a Destruction Inspection By Date COMMENTS o ��' 3LL4 P l SEP 0 1 2011 SAN JOAQUIN COUN ENVIRONMENTAL Area D 4 1 `t ' ! ('4 �t U'., Employee ID# PE Codes SC Info JOB ADDRESS CITY/ZIP Amount Date Permit/ Invoice # Well ID# Remitted Service Request # ( ;i CROSS SIF41EET i WkirvjPN PARCEL S LAND USE APPLICATION # OWNER \f r- i` I G/ PHONE OWNER ADDRESS n c C> �L L I �L' CITY/STATE/ZIP 1PLO Eft i731 No CONTRACTOR W P, PHONE CONTRACTOR ADDRESS CITY/STATE/ZIP C-57 WELL DRILLING LICENSE NUMBER U 2)/� EXPIRATION DATE ^ I PERFORATION CONTRACTOR PHONE PERFORATION CONTRACTOR ADDRESS CITY/STATE/ZIP C-57 Well Drilling License Number Expiration Date 77 -1 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 ❑ Dry ❑ Replacemen Well ❑ Caved In ❑ Pit Well Inactive El Test Hole Detected / Suspected Well Water Contaminant(s) Adjacent property with contamination (Address) Known Soil / Water contaminants at adjacent property EXISTING WELL CONSTRUCTION DETAILS X Open Bottom ❑ Gravel Pack Uncased ❑ Other Well Log copy attached ❑ Yes ❑ No Grout Seal ❑ No ❑ Yes ft 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 inches Total Depth 12� ft Depth to Water 1£ ft Depth of Casing ; L. I ft bgs DESTRUCTION SPECIFICATION n , Sealing Material from _ ft bgs to 1-_ ft bgs Filler Material from ft bgs to ft bgs Well casing to be perforated by one of the following methods: from ft bgs to It bgs ❑ Mills Knife _ Number of cuts every ft 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 (94 lb bag / 5-6 gal water) Sand Cement ' ' sack mix / 7 gal water Bentonite Pellets Bentonite (20%solids) ufacturer Spec % solids % Name Specs on File Specs Submitted Placement Method '.mpe Free Fall Other Seal Completion Complete ushroom Cap 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 1 AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION LAWS. <-L7 Ii CONTRACTORS CE REQUIRED FOR INSPECTIONS TITLE \J P DATE I `Nt Cyon IL AYMEN DEPARTMENT USE ONLY Application Accepted By Date ` I L ( -a Destruction Inspection By Date COMMENTS o ��' 3LL4 P l SEP 0 1 2011 SAN JOAQUIN COUN ENVIRONMENTAL Area D 4 1 `t ' ! ('4 �t U'., Employee ID# PE Codes SC Info Received Check#/ By Cash Amount Date Permit/ Invoice # Well ID# Remitted Service Request # EHD 43-08 WELL DESTRUCTION PERMIT 10/5/07 a 0 144