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WELL DESTRUCTION PERMIT P,/ PUBLIC WATER SYSTEM ❑ Yes ❑ No SAN JOAOUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 East Hazelton Avenue - STOCKTON CA 95205 - (209) 468-3420 NON-REFUNDABLE PFRMIT Cal I /9nm Qr,R_7CQ7 FnD Imencf rinnic CYDIDCC I Vc 0--.. n.�� ,....- . JOB ADDRESS �9� f7�/ CITY/ZIP ti CROSS STREET I APN 10 `�(O PARCEL SIZEX 017LAND USE APPLICATION OWNER /.� ��%� PHONE OWNER ADDRESS CITY/STATE/ZIP� CONTRACTOR PHONE 2-0 -T CONTRACTOR ADDRESS_ 0 O AC CITY/STATE/ZIPZ4tjjf; /' c%S Z y A— C-57 WELL DRILLING LICENSE NUMBER !jL(e6 l Z EXPIRATION DATE PERFORATION CONTRACTOR PHONE PERFORATION CONTRACTOR ADDRESS Ar CITY/STATE/ZIP • ❑ C-57 Well Drilling License Number Expirahvto to ❑ Bureau of Alcohol, Tobacco and Firearms - Users of High Explosives License Number Expiratio ot" 11 24. ❑ CHP Hazardous Material Transportation for Explosives License Number Expo% _ rvla ❑ San Joaquin County Sheriff -Coroner Explosives Application and Permit License Number E�TT C�O v ❑ California Occupational Safety Health - Blaster License Number Explratik S REASON FOR DESTRUCTION ❑ Dry ❑ Replacement Well ❑ Caved In ❑ Pit Well M Inactive ❑ Test Hole Detected/Suspected Well Water Contaminants) Adjacent property with contamination (Address) Known Soil/Water contaminants at adjacent property_ EXISTING WELL CONSTRUCTION DETAILS ❑ Open Bottom ❑ Gravel Pack ❑ Uncased ❑ Other Well Log copy attached ❑ Yes ❑ No Grout Seal ❑ No ❑ Yes _ It below ground surface (bgs) Hole Diameter inches Well Conductor Casing ❑ Ye �,] No Depth of Conductor Casing ft bgs Diameter of Conductor Casing inches 47 A Well Casing Diameter inches Total Depth_It Depth to WaterIt Depth of Casing _ ft bgs DESTRUCTION SPECIFICATION Sealing Material from 1-�/ ft bgs to ft bgs Filler Material �P o -n, js _ from ft bgs to ft bgs Well casing to be perforated by one of the following methods: _from _ ft bgs to ft 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 m&17 gal water Rc.- Bentonite Pellets A/Bentonite (20% solids) D Manufacturer Spec % solids % Name i Specs on File _i Specs Submitted Placement Method Pumped 0<_ Free Fall Other Seal Completion X—' Complete with Mushroom Cap 3 ft bgs i 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. MINIPAUM 24 OUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS CONTRACTORS SIGNATURE /�^� TITLE O 7i IZ DATE 3 - 2,"1 / �{ EPARTMENT USE ONLY Application Accepted By Date 3a w Area 7 Destruction Inspection By Date Employee 't COMMENTS PE SC Receivedhec _.... -... - - ........ Permit/Invoice # Well ID# E Info i ?,a I_�_,l. Remitted Service Request # U / Fsh/� Woo O 275 Qo S I is I . ........... . ... ......... . . ...... ........... . (� ........ ........ . .. ......... ... . .... . : i. ......... I . ... ........... ........... ..... ........... ............ . . ........ .. ...... . ....... ... . . ..... ........... I .f.. k, _.. . ;._. .. _ ... .... .. jp_ .... ...... _ -. 1 .... ..1...... ... �. ... ... ......... i _. I ' EPARTMENT USE ONLY Application Accepted By Date 3a w Area 7 Destruction Inspection By Date Employee 't COMMENTS PE SC Receivedhec Amount Date Permit/Invoice # Well ID# Codes Info ash Remitted Service Request # U / Fsh/� Woo O 275 Qo S I is EHD 43-08 WELL DESTRUCTION PERMIT 4/30/12 FA