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I <br />WELL DESTRUCTION PERMIT <br />PUBLIC WATER SYSTEM ❑ Yes ❑ No <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 East Hazelton Avenue - STOCKTON CA 95205 - (209) 468-3420 <br />NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS MoD / / < Aaf <br />CITYRIP L J9 4Z %70 /O / ,7 0,3 Q <br />CROSS STREET 15� PN 7 7� D V i <br />PARCEL SIZE, LANDUSE APPLICATION# <br />QQ _/ 1 <br />OWNER ) � U /C A )e7 / f Gln <br />PHONE 'h D-(",y/�O �^ / f� 6© <br />OWNER ADDRESS !tE <br />CITY/STATE/ZIP <br />t— <br />CONTRACTOR L(% H -C iZ � <br />/ <br />PHONE (/nOl <br />CONTRAC OR ADDRESS d �• ' r/ <br />� <br />CITY/STATE/ZIP T44 6 Q `�, f � ^J ,?d <br />r � <br />C-57 WELL DRILLING LICENSE NUMBER <br />'j q <br />EXPIRATIONDATE <br />PERFORATION CONTRACTOR —C-9 <br />PHONE J v (2)— / <br />PERFORATION CONTRACTOR ADDRE V. D ,cad x � % f a <br />n <br />Q CITY/STATE/ZIP (,�iDO w� (" i4 / ,57 2 6 <br />0' C-57 Well Drilling <br />License Number "CA " ^ Expiration Date <br />12/ Bureau of Alcohol, Tobacco and Firearms - Users of High Explosives <br />License Number -7-1- 7-4" ^ 90i(J1 Expiration Date 1.2 /'� <br />❑ CHP Hazardous Material Transportation for Explosives <br />License Number P3, &-d-xpiration Date 'Z' <br />❑ San Joaquin County Sheriff -Coroner Explosives Application and Permit <br />License Number Expiration Date <br />❑ California Occupational Safety Health - Blaster <br />License Number Expiration Date <br />REASON FOR DESTRUCTION ❑ Dry ❑ Replacement Well Caved In ❑ Pit Well ❑ Inactive ❑ Test Hole <br />Detected/Suspected Well Water Contaminant(s) <br />Adjacent property with contamination (Address) <br />Known Soil/Water contaminants at adjacent property <br />EXISTING WELL CONSTRUCTION DETAILS ❑ Open Bottoms B -"Gravel Pack ❑ Uncased ❑ Other <br />Well Log copy attached ❑ Yes JYNo Grout Seal 2-N, ❑ Yes _ <br />___ It below ground surface (bgs) Hole Diameter inches <br />Well Conductor Casing ❑ Yes �Irl- No Depth of Conductor Casing _ ____„ <br />ft bgs Diameter of Conductor Casing inches <br />Well Casing Diameter_ .� _ inches Total Depth It Depth to Waterft Depth of Casing ft bgs <br />DESTRUCTION SPECIFICATION <br />Sealing Material from -_ __ft bgs to � ft bgs Filler Material_ <br />_ from _ ft bgs to _ ft bgs <br />Well casing to be perforated by one of the following methods: <br />___from _ _ It bgs to _ ft bgs <br />❑ Mills Knife Number of cuts every ft and/or <br />� r <br />ff7Explosives B' Detonating cord Er with projectiles everyft <br />without projectile S 14A, i <br />❑ Detonating) ord[�nd bo sters ❑ with projectil s ev ry <br />( A' <br />t ❑ without projecti <br />❑ Other 2% (, �Af�i iia A �O � 44 "'- <br />qr <br />tS� J d iJG � l 3' 40 00 e <br />Sealing Material Neat Cement (9( 4 H/ bag/5 6 gal water) Sand CeAnt <br />sack mix/7 gal water Bentonite Pellets <br />✓Bentonite (20% soli ) Manufacturer Spec % solids % Name <br />_ Specs on File Specs Submitted <br />Placement Method Pumped L Free Fall <br />Other <br />Seal Completion Complete with Mushroom Cap ;L6V Vft bgs <br />Complete to Existing Surface Pad <br />I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br />JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br />CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br />WORKERS COMPENSATION WS. <br />IMU 24 O R ADVANCE NOTICE REQUIRED <br />�tC <br />FOR <br />� )INSPEpCTIO S <br />y � J <br />CONTRACTORS SIGNATURE TITLE 1 C/� �j DATE <br />... .... <br />Ll .. ........ . . ..... . . . ........ . ............ ... ......... i --- - ----- <br />PE <br />Codes <br />SC <br />Info <br />Received <br />B <br />Check# <br />a <br />Amount <br />Remitted <br />Date <br />Permit/ <br />est # <br />Service R73Z <br />Invoice # <br />Well ID# <br />r <br />QCs 7 <br />o3 qw'� <br />EHD 43-08 WELL DESTRUCTION PERMIT <br />4/30/12 <br />