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WELL DESTRUCTION PERMIT P /& <br />I PUBLIC WATER SYSTEM ❑ Yes XNo <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 East Hazelton Avenue - STOCKTON CA 95205 - (209) 468-3420 <br />JON -REFUNDABLE PERMIT CALL (209) 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />I JOB ADDRESS V <br />CITY/ZIP �/i I O <br />I CROSS STREETU I <br />PARCEL SIZE LLAND USE APPLICATION # <br />� r 1^APIN <br />A 0" V+t `ot <br />Date <br />OWNER / � V' 1 r ` <br />PHONE <br />OWNER ADDRESS <br />J <br />y 4I t ' <br />CONTRACTOR <br />yCCITY/STATE/ZIP c t^ <br />I`'tNE 2U�. <br />h <br />r) <br />CONTRACTOR ADDRESS Iy I �N' V in I 1/V�/+/��', <br />CIITY/STATE21P <br />^ <br />C-57 WELL DRILLING LICENSE NUMBER " `lP-1 EXPIRATION DATE <br />PERFORATION CONTRACTOR <br />PHONE <br />PERFORATION CONTRACTOR ADDRESS <br />CITY/STATE/ZIP <br />IC-57 Well Drilling <br />License Number % U Expiration Date vt <br />❑ Bureau of Alcohol, Tobacco and Firearms - Users of High Explosives <br />License Number Expiration Date <br />❑ CHP Hazardous Material Transportation for Explosives <br />License Number Expiration Date <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 `K, 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 Bottom ❑ Gravel Pack ❑ Uncased ❑ Other <br />Well Log copy attached ❑ Yes ❑ No Grout Seal ❑ No ❑ Yes <br />ft below ground surface (bgs) Hole Diameter inches <br />Well Conductor Casing ❑ Yes ❑ No Depth of Cond ctor sing <br />It bgs Diameter of Conductor Casing inches <br />Well Casing Diameter�inches Total Depth kt Depth to Water It Depth of Casing _ It bgs <br />DESTRUCTION SPECIFICATION <br />�v <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 />❑ Explosives ❑ Detonating cord ❑ with projectiles every <br />ft ❑ without projectile <br />❑ Detonating cord and boosters ❑ with projectiles every <br />ft ❑ without projectile <br />❑ Other <br />Sea <br />Sea ' g Material Neat Cement (94 lb bag/5-6 gal water) 1 Sand Cement <br />sack mixll gal water Bentonite Pellets <br />(20% s Ids) Manufacturer Spec % solids % Name <br />— I Specs on File I Specs Submitted <br />Placement Method Pumped I Free Fall r I <br />Other <br />Seal Completion Complete with Mushroom Cap ft 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 LAWS. <br />CONTRACTORS SIGNATURE <br />CE NOTICE REQUIRED FOR INSPECTIONS <br />TITLE TE 23 L <br />OqQ�/ <br />yLTy D°gyp RT� CNS <br />,FNT <br />54 . D PARTMENT USE ONLY /(n� <br />Application Accepted By Date —r Iv Area <br />Destruction Inspection By _ - _ Date n�YJ 1 �i Employee ID# <br />COMMENTS <br />PE <br />Code <br />V <br />ReceivedPCheck#1 <br />B <br />Amount <br />Remitted <br />Date <br />I <br />Invoice # <br />Well ID# <br />Obo <br />G� <br />3 <br />ZW <br />('2y <br />OqQ�/ <br />yLTy D°gyp RT� CNS <br />,FNT <br />54 . D PARTMENT USE ONLY /(n� <br />Application Accepted By Date —r Iv Area <br />Destruction Inspection By _ - _ Date n�YJ 1 �i Employee ID# <br />COMMENTS <br />PE <br />Code <br />SC <br />Info <br />ReceivedPCheck#1 <br />B <br />Amount <br />Remitted <br />Date <br />Permit/ <br />Service Re uest # <br />Invoice # <br />Well ID# <br />Obo <br />G� <br />3 <br />ZW <br />('2y <br />EHD 43-08 WELL DESTRUCTION PERMIT <br />4/30/12 <br />r <br />n <br />r <br />