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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 y� b 0 y JOB ADDRESS G Q e- V I (A Q- J CITY/ZIP Tlc y q5.3 oit CROSSSTREET a tr G1 iS a APN ,3 O T Q —JV PARCEL SIZE 2)' -LAND USE APPLICATION # OWNER 1 G r PHONE yy�t OWNER ADDRESS (� P/ CITY/$TATE/zIP 1• r-f1l Q� CONTRACTOR Rd r y} n PHONE // CONTRACTOR ADDRESS Z -O( 4rCA-'gIRd rA��r Ti loo CITYISTATEIZIP S+oc. V '151-0 C-57 WELL DRILLING' / 1pLICENSE tNUMBER I /� EXPIRAT �ON%DATE / �'/ PERFORATION CONTRACTOR V l v-'7 (SIJ I t IIIA / _ PHONE 9 1 +C � — -7 / ©© PERFORATION CONTRACTOR ADDRESS _'p O� �[s Cr- OrIVe CITY/STATE/ZIP 9�,,n�t III C-57 Well Drilling License Number c.C/ 0 Expiration Date 4 '3 0--7 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 Ili 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 it No Depth of Conductor Casing ft bgs Diameter of Conductor Cas.. inches Well Casing Diameter Z inches Total Depth —W --ft Depth to Water #t -/s ft Depth of Casing ft bgs DESTRUCTION SPECIFICATION ' Sealing Material from d It 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 41b bag /5-6 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 Methodumpe Free Fall Other Seal Completion Complete Inn 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`INIIMMU/M 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS / I "7 CONTRACTORS SIGNATURE Q ` — / TITLE fro ,SSd O,IoI/ DATE ��/ (9 1 Application Accepted By _ Destruction Inspection By COMMENTS � RE ft�eNT SPS c1 % ��`�`< sA�,�201 N4CT IRpN�F/VOO�N�' O��'ARTA,ENT IRZom DE TMENT USE ONLY ''f'' Date _) l U l Area I 1-(A Data IV J' //:I Employee ID# PE SC Received Check#/ Amount Date Pat" Invoice # Well ID# Codes Info B C sh Remitted Service Request # 4313 o W vn 31 41111,1 l u 5 EHD 43-08�)- WELL DESTRUCTION PERMIT 10/5/07 64 4 q Z-