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WELL DESTRUCTION PERMIT F'-'0' <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-RFFtINDARLF PFRMIT CAI 1 MD01 Q53-7RQ7 FnD IMQD=r TInA1C 1=YDIRCC i VCAO Conran IIATC 110011�M <br />JOB ADDRESS & CITY/ZIP <br />I SC <br />Info <br />CROSS STREET �� <br />/ Za APN +/(� PARCEL SIZE • <br />LAND USE A LIGATION # <br />OWNER �/�/�� , ,� 1 PHONE <br />OWNER ADDRESS CITY/STATE/ZIP <br />Invoice # <br />CONTRACTOR �li� / PHONE�Q "J <br />gg <br />3 �i7 J I ZpJ ZO <br />/J <br />CONTRACTOR ADDRESS 0 D . �pj,X CITY/STATE/ZIP of 9sz yi <br />C-57 WELL DRILLING LICENSE NUMBER 4'v -9- 3 EXPIRATION DATE <br />PERFORATION CONTRACTOR PHONE <br />PERFORATION CONTRACTOR ADDRESS CITY/STATE/ZIP <br />❑ C-57 Well Drilling License Number <br />Expiration Date <br />❑ Bureau of Alcohol, Tobacco and Firearms - Users of High Explosives License Number <br />Expiration Date <br />❑ CHP Hazardous Material Transportation for Explosives License Number <br />Expiration Date <br />❑ San Joaquin County Sheriff -Coroner Explosives Application and Permit License Number <br />Expiration Date <br />❑ California Occupational Safety Health - Blaster License Number <br />Expiration Date <br />REASON FOR DESTRUCTION ❑ Dry ❑ Replacement Well ❑ Caved In ❑ Pit Well <br />41rL 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 ❑ <br />Uncased ❑ Other <br />Well Log copy attached ❑ Yes ❑ No Grout Seal ❑ No ❑ Yes ft below ground surface <br />(bgs) Hole Diameter inches <br />Well Conductor Casing ❑ Yes ❑ No Depth of Conductor Casing ft bgs Diameter of Conductor Cas' inches <br />Well Casing Diameter!T7 inches Total Depth __r3 It Depth to Water_ft <br />Depth of C n Ipgs <br />DESTRUCTION SPECIFICATION / <br />i <br />Sealing Material from eft bgs to _ 3 ft bgs Filler Material��raoj!- <br />from _ ft9 RD ff bgs <br />Well casing to be perforated by one of the following methods: from <br />ft bgs t4 _ <br />❑ Mills Knife _Number of cuts every ft and/or <br />E �OAQV/N <br />OUN7y <br />❑ Explosives ❑ Detonating cord ❑ with projectiles every ft <br />❑ without �f>�j l OAf;,, <br />❑ Detonating cord and boosters ❑ with projectiles every ft <br />❑ without projectil oEpyRNr44 <br />MFNT <br />❑ other <br />Sealing Material Neat Cement (94 Ib bag/5-6 gal water) Sand Cement sack <br />mix17 gal water Ac=Bentonite Pellets <br />Bentonite (20% solids) - Manufacturer Spec % solids_ % Name <br />Specs on File i Specs Submitted <br />Placement Method Pumped Free Fall Other <br />Seal Completion &—/Complete with Mushroom Cap _ ft bgs i 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 />MIN�M 24H'ADVANCE NOTICE REQUIRED FOR <br />CONTRACTORS SIGNATURE TITLE DATE <br />E � i <br />....... j <br />Application Accepted By - <br />Destruction Inspection By <br />COMMENTS <br />PARTMENT USE ON Y <br />Date Area <br />Date 75 Employee ID# <br />PE <br />Codes <br />I SC <br />Info <br />Received <br />By- <br />he <br />---C—ash <br />Amount <br />HemittqdDate <br />Permit/ <br />Service Request # <br />Invoice # <br />Well ID# <br />00 <br />LopeC+ --;5s1 <br />EHD 43-08 WELL DESTRUCTION PERMIT <br />4/30/12 <br />