WP0038073 - Laserfiche WebLink

Home Browse Search

JELL DESTRUCTION PERK"r PUBLIC WATER SYSTEM ❑ Yes ❑ No SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 East Hazelton Avenue - STOC.KTON CA 95205 - (209) 468-3420 NON-REFUNDABLE PERMIT CALL (209) 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS Aa A;n "eefeI_CITY21P 72e < Y '9S-1? 7 7 CROSS ST ET fiiI A.0 , APN 090 do© *3 4/1 (aPARCEL SIzk?9•7 LAND USE APPLICA110N #__ OWNER Za a/�r f Z. PHONE S D ' OWNER ADDRESS J t CIT /STATE/CONTRACTOR ZtJ �Wj e O �"/` 77'F'HOONE 6 Y Z CONTRACTOR ADDRESS . /� L, CITY/STATE/ZIP C3 - 7C-57 WELL DRILLING LICENSE NUMBER 3 y.2 Z � EXPIRATION DATE S` �%' J 9 . 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 13o-ITiactive ❑ Test Hole Detected/Suspected Well Water Contaminant(s) Adjacent property with contamination (Address) — Known Soil/Water contaminants at adjacent property-- EXISTING roperty_EXISTING WELL CONSTRUCTION DETAILS ❑ Open Bottom D Gravel Pack Uncased ❑ Other Well Log copy attached ❑ Yes @;-I o Grout Seal ❑ No ❑ Yes it below ground surface (bgs) Hole Diameter inches Well Conductor Casing ❑ Yes ❑ No Depth of Conductor Casing 1t bgs Diameter of Conductor Casing inches Well Casing Diameter_ 6_ inches Total Depth _ it Depth to Water -_ it Depth of Casing - it bgs DESTRUCTION SPECIFICATIONd Sealing Material from _ 0, C7 -_ft bgs to it bgs Filler Material rvW ( aji!!�from _ _ it bgs to. a ft bgs Well casing to be perforated by one of the following methods: from _ it bgs to - it bgs ❑ Mills Knife Number of cuts every _ it and/or ❑ Explosives ❑ Detonating cord ❑ with projectiles every it ❑ without projectile ❑ Detonating cord and boosters ❑ with projectiles every _ it ❑ without projectile ❑ Other_ _ Sealing Material Neat Cernent (94 lb bag/5-6 gal water) Sand Cement sack mix/7 gal water Bentonite Pellets ✓Bentonite (20% solids) Manufacturer Spec % solids °o Name _ Specs on File Specs Submitted Placement Method ✓ Pumped Free Fall Other Seal Completion —Complete with Mushroom Cap 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. INI UM 24 H R ADVANCE NOTICE REQUIRED FOR INSPECTIONS g CONTRACTORS SIGNATURE TITLE (ivvl%T%� 1 Jnrl DATE Application Accepted By -; Destruction Inspection By — COMMENTS r Y3 H" �IR� v/h 7Iy f1NMP.C 0C/Ai� EPARTMENT USE O LY IS1- - -- Date —- Area -- J Date 03 Z3 Employee ID# PE SC Received he Amount Permit/ Codes Info B ash Remitted Date Service Re uest #Ilk Invoice # Well ID# EHD 43-08 WELL DESTRUCTION PERMIT 4/30/12 s n Y n