WP0037911 - Laserfiche WebLink

Home Browse Search

WELL DESTRUCTION PERMIT PUBLIC WATER SYSTEM ❑ Yes ❑ No SAN JOACUIN 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 ADDRESSI m., T . /Ae /l "011 RA CITY/ZIP l i/4 /% , C, c 1 n CROSS STREET �Q)QJ,, LI oxw APN 1{2f- 022--0,5 QPARCELSIZE LAND USE APPLICATION# OWNER /'! O 7 PHONE © 7- - � .7 OWNER ADDRESS �6 / 1 �y �j� CITY/STATE/ZIP (,),# Jq lir, e C%i• ( CONTRACTOR I rr PHONE .26,57 - CONTRACTOR ADDRESS I CITY/STATE/ZIP C-57 WELL DRILLING LICENSE NUMBER 7 J EXPIRATION DATE PERFORATION CONTRACTOR PHONE - PERFORATION CONTRACTOR ADDRES D 0 CJ ,K 17 1 O CITY/STATE/ZIP ❑ C-57 Well Drilling License Number Expiration D f� Bureau of Alcohol, Tobacco and Firearms - Users of High Explosives License Number? eIt' 1/ 3- 33� Expiration Da a /2 -/•20 IV CHP Hazardous Material Transportation for Explosives License Number /J7G/ ? Expiration Date -71-loo Joaquin County Sheriff -Coroner Explosives Application and Permit License Number Z 7m9— Expiration Date ^ "Y-/ California Occupational Safety Health - Blaster License Number 380/ Expiration Date fZ -A 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 B--taravel Pack ❑ Uncased ❑ Other Well Log copy attached ❑ Yes P,*"'No Grout Seal ❑ No ❑ Yes _ It below ground surface (bgs) Hole Diameter inches Well Conductor Casing ❑ Yes 91No Depth of Conductor Casing _ ,r__ _fl bgs Diameter of Conductor Casing __. inches Well Casing Diameter ilf inches Total Depth !� _ ft Depth to Water___.__ ft Depth of Casing _ ft bgs DESTRUCTION SPECIFICATION Sealing Material from 90 ----ft bgs to .._ �_Q_ It bgs Filler Material _ --from _ it bgs to ft bgs Well casing to be perforated by one of the following methods: _ _from _) It bgs to___1_ij t_ ft bgs ❑ Mills Knife Number of cuts every It and/or _ 27 Q S 9etonating cord ❑ with projectiles every Explosives ;"Det Detojiati g cord and boosters ❑ wit�i projectile eery ft ❑ without projectile,6,;;)•w It ❑ without projectilef,L ❑ Other <A& Z c�AiRQe�3 i�X� rv�� (t o _ Sealing Maeerial Neat Cement (94 Ib b� ag/5 G g water) Sand Cement 1 {Z,_ sack mix/7 gal water Bentonite Pellets Bentonite (20% solids) Manufacturer Spec % solids____ _% Name Specs on File Specs Submitted Placement Method P--- Pumped-Tttmv( Free Fall Other Seal Completion +'Complete with 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. CONTRACTORS SIGNA INIMU TR AN CE NOT� ICE REQUIRED FOR INSPECTION \\TITLEDATE -a 1 - l D E P A R T M ENT USE O N Y Application Accepted By 1 L' _ Date `i ( _._ Area ww�.,Zl a� I Destruction Inspection By ra `�� _ _ __ Date 66/ ��___ ___... _ iu^ Employee IDN — r COMMENTS T PE Sc Info Received B Chec s Amount Remitted Date Permit/Codes Service Request # Invoice # Well ID# _ EHD 43-08 WELL DESTRUCTION PERMIT 4/30/12