WP0037563 - Laserfiche WebLink

Home Browse Search

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 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS lyl/CITY/ZIP CROSS ST T PARCELS D iy LAND SE APPICAT N # OWNER PHONE L" OWNER ADDRES L1, 43 - CITY/S TE/ZIP , CONTRACTOR C PHOt� 111 CONTRACTOR ADDRES L CITY/STATE/ZIP C-57 WELL DRILLING LICENSE NUMBER EXPIRATION DATE PERFORATION CONTRACTOR PHONE PERFOR TION 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 ❑ 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 P Gravel Pack ❑ Uncased ❑ Other Well Log copy attached ❑ Yes ❑ No Grout Seal ❑ No 8 Yes 1( �. ft 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 Cr inches Total Depth I `S U It Depth to Water ft Depth of Casing ft bgs DESTRUCTION SPECIFICATION I� Sealing Material from /80 ft bgs to (--'t> ft bgs Filler Material �j �� v' from ft 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 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 Ib bag/5-6 gal water) ' Sand Cement sack mix17 gal water Bentonite Pellets C-.Aentonite (20% solids) Manufacturer Spec % solids % Name Specs on File Specs Submitted Placement Method — Pumped Frs^ Fnll Other Seal Completion `Complete with Mushroom Cap C4tweo6e ft bgs Complete iv Existing Su face Pad i 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. M 41MUM 24 U ADVANCE NOTICE REQUIRED FOR INSPECTIONS CONTRACTORS SIGNATURE TITLE DATE LJ j r d dA�( �r tom. ,,.�_- y, w {..... ,'g � - -,._.{....,.,..a,.............,............ _..i....»,. Y • I Iso s�� s Oki;............ . 1 ..... ..._L .- r .....__. _. ,......L._..._4 t_II -.__..___. _.. _. _...._ ....... ._ _.. V7 Ir EPARTMENT USE 0NiiLY Application Accepted By Date I 3 i Area �,n /' a /1 lc,/,g Destruction Inspection By Date Employee ID#AHMED COMMENTS I AQ r ' n r jp i I < �. l` 1 b k rP c 2� , 1117,0 -tSy I PE Codes Sc Info Received Ely. ec ash I Amount Remitted Date Permit/ Service Re uest # Invoice # Well III q37� � 1 ��I 1 `' EHD 43-08 WELL DESTRUCTION PERMIT 4/30/12