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r i WELL DESTRUCTION PERMIT PUBLIC WATER SYSTEM ❑ Yes ❑ 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 JOB ADDRESS 1E.Fegi,-ade-ro V nu e- CITY/ZIP. Tra c y '[ S j o t CROSS STREETPro A lT Ct 5 C APN :2) 3 a 70 � / PARCEL SIZE X`LAND USE APPLICATION # Y OWNER 1Ina. PHONE y� OWNER ADDRESS S Ol P/ ! CITYISTATE/ZIP M a O CONTRACTOR }� PHONE u'm �i' -13 / p CONTRACTOR ADDRESSZ-aol P r O 7j� # OD CITY/STATE/ZIP 5T1114'YJ C-57 WELL DRILLING LICENSE NUMBER EXPIRATION DATE PERFORATION CONTRACTOR V ,( W I i I 1 1 A PHONE_Log) +6 ^ '7700 PERFORATION CONTRACTOR ADDRESS D l� pu. C/ C YI V� CITY/STATE/ZIP m C-57 Well Drilling License Number Expiration Date 4 '30:; 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 If Gravel Pack ❑ Uncased ❑ Other Well Log copy attached ❑ Yes ❑ No Grout Seal ❑ No 4 Yes It below ground surface (bgs) Hole Diameter _ inches Well Conductor Casing ❑ Yes -d No Depth of Conductor Casing ft bgs Diameter of Conductor Cas.. inches Well Casing Diameter Z inches Total Depth _?&—ft Depth to Water /0 -IS ft Depth of Casing it bgs DESTRUCTION SPECIFICATION ' Sealing Material from b ft bgs to ;? 10 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 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 41 bag 15-6 gal water) Sand Cement sack mix / 7 gal water Bentonite Pellets Bentonite (20% so ds) Manufacturer Spec % solids _% Name Specs on File Specs Submitted Placement Method 4r.mpel> Free Fall Other Seal Completion Complete wl Mushroom 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 I AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION LAWS. //^,M`INIMU/M 24/HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS CONTRACTORS SIGNATURE ( _ IM!-�l'� TITLE N 'SSO0101/ DATE ` /"l �-7 PA 'Y41 CLc jV�� S l SAN HT'pEpgRTT CNS MENT D TMENT USE ONLY Application Accepted By Date U % Area Destruction Inspection By Date / Employee ID# COMMENTS ip .I ZU m e kr3 fd Ir) / PJ arc Y PE Sc Received Check#I AmountDate Permit Invoice # Well ID# Codes Info 13Cash Remitted Service Reguest# 43,f) ® WF 1 43? III, k lh.1101ft-3157g-3p -603-1M EHD 43-08WELL DESTRUCTION PERM 10/5/07 64 40 L �/� L )Z—