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a WELL DESTRL)c"r fJN PERMIT Q ✓ PUBLIC WATER SYSTEM ❑ Yes ENo SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 East Hazelton Avenue - STOCKTON CA 95205 - (209) 468-3420 NON-REFUNDABLE PERMIT CALL (2091953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS �� / C 1974 (�V CITY/ZIP AIA,4 C _,: LL- Cj JJ J u� J ^� /� CROSS STREET w��f APN 1 I l V U ' "I PARCELSIZE LAND USE APPLICATION # t' .- 11 OWNER e I • 1 W i1 le WOr 4-h d 't>lanPffONE Date OWNER ADDRESS 3 3 CITY/STATE/ZIP M ,�, 11 7 Cc q `s .? 3 CONTRACTOR iC / 6 G/ S 7- PHONE ✓ �/G CONTRACTOR ADDRESS P CJ U X !� �/ V CITY/STATE/ZIP L �� f l A g s a G I fR_ C-57 WELL DRILLING LICENSE NUMBER LK I Z 3 EXPIRATION DATE -12-3/-)i PERFORATION CONTRACTOR PHONE PERFORATION 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 N Open Bottom ❑ Gravel Pack ❑ Uncased ❑ Other Well Log copy attached ❑ Yes N 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 _ _ ft Depth to Waterit Depth of Casing It bgs DESTRUCTION SPECIFICATION Sealing Material from _ 71 0_ft bgs to ft bgs Filler Material_-%1�YL from ft bgs to It 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 mix17 gal water Bentonite Pellets Bentonite (20% solids) Manufacturer Spec % solids —% Name— _ i Specs on File Specs Submitted Placement Method / Pumped P< Free Fail Other Seal Completion Complete with Mushroom Cap 3_ It 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. MIIMUM24 OUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS /f CONTRACTORS SIGNATURE ��=t TITLE K �= DATE AJ DEP—ARrTMENT Application Accepted By - Destruction Inspection By COMMENTS JZ O USE ONLY Date l al- I I 7 /7 Area Date (-1 Employee ID#A h m e d PE SC Info Received B ec s Amount Remitted Date Permit/Codes Service Request # Invoice # Well ID# 433 Y�I J 1 EHD 43-08 WELL DESTRUCTION PERMIT 4/30/12