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WELL DESTRUCTION PERMIT PUBLIC WATER SYSTEM ❑ Yes JNo 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 I (� O a v '3 '?4 G^f) I e y CITY/ZIP /-/LwIiP�.L-. R5337 I,'<' CROSS STREET 1 I w y 0 APN d `11 � 3 1 � � � PARCEL SIZE _LAND USE APPLICATION # T s Date OWNER B C h A r T PHONE OWNER ADDRESS 2 U �� S• u s+' n fC CITY/STATE/ZIPrA7 .(G 17 J CONTRACTOR 0 /e PHONE �O�- CONTRACTOR ADDRESS CITY/STATE/ZIP / _V_ C-57 WELL DRILLING LICENSE NUMBER 7} LJ —EXPIRATION DATE (Z - 31-1.5 PERFORATION CONTRACTOR 2 PHONE J Z-7- Z 0 PERFORATION CONTRACTOR ADDRESS CITY/STATE2IP `PLtii G -�7 SZ y ❑ 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 ❑ 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 It Depth to Water_ __— ft Depth of Casing ft bgs DESTRUCTION SPECIFICATION Sealing Material fromt bgs to _3 ft bgs Filler Material�4 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) I i Sand Cement sack mix17 gal water X Bentonite Pellets Bentonite (20% solids) Manufacturer Spec % solids —% Name _ Specs on File Specs Submitted Placement Method Pumped /- Free Fall [_i Other Seal Completion d -Complete with Mushroom Cap 3 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. MIN MUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS CONTRACTORS SIGNATURE TITLE 1 L4-L1� DATE /Z-/ a.._ .._.. _. . 1' A i 1... . ( ...,... p, �.. ,S,q/y'1Q� EPARTMENT USE ONLY Application Accepted ByDate Area / v, Destruction Inspection By Date 24 1-11 Employee ID# A it YY) e COMMENTS PE Codes SC Info Received B hec ash Amount Remitted Date PermiU Service Request # Invoice # Well ID# `l3 I6 I 3 Y,2 4, 1 � 0 Mll C, 00 EHD 43-08 WELL DESTRUCTION PERMIT 4/30/12