Laserfiche WebLink
�v r <br />WELL DESTRUCTION PERMIT <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 /9(191 953-7897 Fna IRICGFrTIrVUC FYPIRFC I VcnD CDnee nA= Ic011Cn <br />JOB ADDRESS S <br />CITY/ZIP <br />Received <br />B <br />'I -ch -60W <br />ash <br />CROSS STREET APN Zo Z PARCEL SIZE I <br />LAND USE APPLICATION # <br />Invoice # <br />OWNER <br />PHONE <br />b <br />OWNER ADDRESS <br />CITY/STATE2IP <br />��" <br />. (�►�p <br />/ <br />CONTRACTOR y 6/10 SS <br />PHONE 710 -,P ' <br />30 7 3/ZO <br />CONTRACTOR ADDRESS 0- A", /O � <br />CITY/STATE/ZIP� <br />v -je e � `l:5 0 �J <br />C-57 WELL DRILLING LICENSE NUMBER KLT}/ J7,;3 <br />EXPIRATION DATE <br />17- — P9 <br />PERFORATION CONTRACTOR <br />PHONE <br />PERFORATION CONTRACTOR ADDRESS <br />CITY/STATE/ZIP <br />❑ C-57 Well Drilling <br />License Number <br />Expiration Date <br />❑ Bureau of Alcohol, Tobacco and Firearms - Users of High Explosives <br />License Number <br />Expiration Date <br />❑ CHP Hazardous Material Transportation for Explosives <br />License Number <br />Expiration Date <br />❑ San Joaquin County Sheriff -Coroner Explosives Application and Permit <br />License Number <br />Expiration Date <br />❑ California Occupational Safety Health - Blaster <br />License Number <br />Expiration Date <br />REASON FOR DESTRUCTION ❑ Dry ❑ Replacement Well ❑ Caved In ❑ Pit Well <br />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 />It below ground surface (bgs) Hole Diameter <br />inches <br />Well Conductor Casing ❑ Yes ❑ No Depth of Conductor Casing <br />ft bgs Diameter of Conductor Casing <br />inches <br />Well Casing Diameter 10 inches Total Depth /4Q.ft Depth to Water_ ft <br />Depth of Casing <br />ft bgs <br />DESTRUCTION SPECIFICATION <br />Sealing Material from' D ft bgs to _ _ _ ft bgs Filler Material <br />from _ ftbgs to <br />ftbgs <br />Well casing to be perforated by one of the following methods: <br />from <br />ft bgs to ft bgs <br />❑ Mills Knife Number of cuts every It and/or <br />❑ Explosives ❑ Detonating cord ❑ with projectiles every <br />ft <br />❑ without projectile <br />❑ Detonating cord and boosters ❑ with projectiles every <br />ft <br />❑ without projectile <br />❑ Other <br />Sealing Material Neat Cement (94 lb bag/5-6 gal water)1 Sand Cement <br />sack mix/1 gal water entonite Pellets <br />Bentonite (20% solids) ii Manufacturer Spec % solids % Name <br />P Specs on File Pecs Submitted <br />Placement Method n Pumped i Free Fall rl <br />Other <br />Seal Completion Ix Complete with Mushroom Cap 15 ft bgs <br />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 />MINIM 24 HOAR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br />CONTRACTORS SIGNATURE TITLE / <br />Application Accepted By <br />Destruction Inspection By <br />COMMENTS <br />3-z-�- <br />-�vd i a �.-"_i <br />302018 <br />.._-- <br />H � R EPME O,Nry <br />L <br />! D • P A R T M ENT USE ON Y <br />Date Area <-hq <br />Yd Date Employe ID# <br />PE <br />Codes <br />SC <br />Info <br />Received <br />B <br />'I -ch -60W <br />ash <br />Amount <br />emitted <br />Permit/ <br />D to Service Request # <br />Invoice # <br />Well ID# <br />b <br />3 <br />EHD 43-08 WELL DESTRUCTION PERMIT <br />4/30/12 <br />