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WELL DESTRUCTION PERMIT PUBLIC WATER SYSTEM ❑ Yes ❑ No SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 600 E MAIN STREET - STOCKTON CA 95202 - (209) 468-3420 Nr1N.RccIINnAR1 F PERMIT rAI I /7f1Q1 QriQ_7RQ7 Eno Iu4zDcrTInA1C EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS , , panrjl� r,�A G� ipI V` i 1 CITY/ZIP CROSS STREET pp�{{'� ��1� I' 1�t I 1 Vy [-el h 1 APN %�?�I I/J� > t� PARCEL SIZE L✓ LAND USE APPLICATION # OWNER SU''li m ft1� C �'�Irl SNl1 IV) 1Siyy °� Ii f I PHONE OWNER ADDRESS r7 1 ' ' �I I' V�f CITY/STATE/ZIP {/V, +y'C` CI L:_7 a P !' CONTRACTOR r4 � 6.S +�' Lt 3 L1(t 11 i W T 1 } _ PHONE CONTRACTOR ADDRESS �t ri (' 1�l'1 CITY/STATE/ZIP �A1� / ,� N J ( / �1 S S 9 C-57 WELL DRILLING LICENSE NUMBER �� ,�, L L [ EXPIRATION DATE ti , j(-- f ' PERFORATION CONTRACTOR PHONE PERFORATION CONTRACTOR ADDRESS CITY/STATE/ZIP .0 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 Inactive ❑ Test Hole Detected/Suspected Well Water Contaminant(s) Adjacent property with contamination (Address) Known Soil/Water contaminants at adjacent property EXISTING WELL CONSTRUCTION DETAILS ❑ Open Bottom -7�. Gravel Pack ❑ Uncased ❑ Other Well Log copy attached ❑ Yes No Grout Seal ❑ No ❑ Yes ft below ground surface (bgs) Hole Diameter inches Well Conductor Casing ❑ Yes No Depth of Conductor casing ftbgs Diameter of Conductor Casing inches Well Casing Diameterinches Total Depth -. ft Depth to Water ft. Depth of Casing ft bgs DESTRUCTION SPECIFICATION i Sealing Material from 0 ft bgs to ft bgs Filler Material i5,(4b'1tu�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 Ib bag/5-6 gal water) :-I Sand Cement sack mix/7 gal water N�<' Bentonite Pellets Bentonite (20% solids) Manufacturer Spec % solids % Name Specs on File Specs Submitted Placement Method - Pumped Free Fall ❑ Other Seal Completion Complete with Mushroom Capft 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. C MIN UM HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS _T�-� TITLE JP II CONTRACTORS SIGNATURE �r'Y � ' DATE v,. A` CIL; ZJW f o pry Z LIJ N w W > 00 zoo. G iU o O 0 p Qul DEPARTMENT USE ONLY, Application Accepted By Date J Area Destruction Inspection By Date Employee I COMMENTS PE SC Codes Info Received By Check#/ CashRemitted Amount Date Permit! Service Request # Invoice # Well ID# EHD 43-08 WELL DESTRUCTION PERMIT 10/5/07 -7 m a 0 z v