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WELL DESTRUCTION PERMIT P'/ <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 /"I %6 f C. CITY/ZIP Ay� � 717 <br />CROSS STREET I 17-0 A P N 2¢� `'71_( O (� PARCEL SIZE /LAND USE APPLICATION <br />OWNER ADDRESS <br />EXISTING <br />CITY/STATE/ZIP /Lli <br />, 9x317 <br />CONTRACTOR &ft2 <br />PHONE ZO? - 32? - 3rZdd <br />CONTRACTOR ADDRESS D 7AC <br />CITY/STATE/ZIP G�jf <br />C / f c7 < Z Z/ <br />,it- C-57 WELL DRILLING LICENSE NUMBER !i L(�6 i <br />EXPIRATION DATE <br />Info <br />PERFORATION CONTRACTOR <br />PHONE <br />Remitted <br />PERFORATION CONTRACTOR ADDRESS <br />CITY/STATE/ZIP <br />pr <br />❑ C-57 Well Drilling <br />License Number <br />Expiratigq to <br />❑ Bureau of Alcohol, Tobacco and Firearms - Users of High Explosives <br />License Number <br />Expiratiot <br />❑ CHP Hazardous Material Transportation for Explosives <br />License Number <br />Ex#m <br />❑ San Joaquin County Sheriff -Coroner Explosives Application and Permit <br />License Number <br />E)R C <br />❑ California Occupational Safety Health - Blaster <br />License Number <br />Expirati6 <br />REASON FOR DESTRUCTION ❑ Dry ❑ Replacement Well ❑ Caved In ❑ Pit Well <br />1T 1 <br />119. 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 />roperty__ <br />EXISTING WELL CONSTRUCTION DETAILS <br />` Well Log copy attached ❑ Yes ❑ No <br />Well Conductor Casing ❑ Yes. A No <br />S Well Casing Diameter_S_*inches <br />N <br />V <br />❑ Open Bottom ❑ Gravel Pack ❑ Uncased ❑ Other <br />Grout Seal ❑ No ❑ Yes It below ground surface (bgs) Hole Diameter _ <br />Depth of Conductor Casing __ _ ft bgs Diameter of Conductor Casing <br />Total Depth It Depth to Water 6 It Depth of Casing <br />inches <br />inches <br />_ It bgs <br />DESTRUCTION SPECIFICATION <br />Sealing Material from 2-9 ft bgs to It bgs Filler Material _�_p.o-n�;l�from It bgs to ft bgs <br />Well casing to be perforated by one of the following methods: _from ft bgs to__ ft bgs <br />❑ Mills Knife Number of cuts every _ft and/or <br />❑ Explosives ❑ Detonating cord ❑ with projectiles every _ ft ❑ without projectile <br />❑ Detonating cord and boosters ❑ with projectiles every ft ❑ without projectile <br />❑ Other <br />Sealing Material Neat Cement (94 lb bag/5-6 gal water) i Sand Cement _ <br />,*/ Bentonite (20% solids) Manufacturer Spec % solids % Name _ <br />Placement Method Pumped AQ.- Free Fall <br />Seal Completion /L Complete with Mushroom Cap 3 ft bgs <br />mix/7 gal water fix- Bentonite Pellets <br />Specs on File Specs Submitted <br />Other <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 />MINI UM 24 OUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br />CONTRACTORS SIGNATURE - TITLE / fLo-P l��in��� DATE 3 <br />�,EPARTMENT <br />Application Accepted Byv <br />Destruction Inspection By <br />COMMENTS <br />USE ONLY �j <br />Date 3a w Area 7 <br />Date Employee rDft <br />PE <br />SC <br />Received <br />heck <br />Amount <br />Date <br />Permit/ <br />Invoice # <br />Well ID# <br />Codes <br />Info <br />ash <br />Remitted <br />Service Request # <br />3,)Poo <br />� 91 L� <br />EHD 43-08 WELL DESTRUCTION PERMIT <br />4/30/12 <br />