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WELL DESTRUCTION PERMIT <br />0 <br />PUBLIC WATER SYSTEM ❑ Yes ❑ No <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 600 E MAIN STREET - STOCKTON CA 95202 - (209) 468-3420 <br />NON-REFUNDABLE PERMIT CALL f20Q1 q51-7947 FnR INSPFr'TIONIA EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS X111 b � ��y, e A <br />CITY/ZIP <br />CROSS STREET Se,,�1 AP <br />PARCEL SIZE LAND USE APPLICATION # <br />OWNER- a n -,., 2 A <br />PHONE --)e l <br />OWNER ADDRESS L, <br />^� <br />CITY/STATE/ZIP *A , CES s �L <br />CONTRACTOR ['- ` �) �Y'r <br />PHONE <br />CONTRACTOR ADDRESS 1G �� �t y 1� <br />y�� <br />CITY/STATE/ZIP / ��L�d t'� <br />C-57 WELL DRILLING LICENSE NUMBER �r; k- f % G _ <br />EXPIRATION DATE <br />PERFORATION CONTRACTOR <br />PHONE <br />PERFORATION CONTRACTOR ADDRESS <br />CITY/STATE/ZIP <br />❑ C-57 Well Drilling <br />License Number Expiration Date <br />❑ Bureau of Alcohol, Tobacco and Firearms - Users of High Explosives <br />License Number Expiration Date <br />❑ CHP Hazardous Material Transportation for Explosives <br />License Number Expiration Date <br />❑ San Joaquin County Sheriff -Coroner Explosives Application and Permit <br />License Number Expiration Date <br />❑ California Occupational Safety Health - Blaster <br />License Number Expiration Date <br />REASON FOR DESTRUCTION ❑ Dry ❑ Replacement Well Caved In ❑ Pit Well ❑ 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 />ft below ground surface (bgs) Hole Diameter inches <br />Well Conductor Casing ❑ Yes ❑ No Depth of Conductor Casing <br />ft bgs Diameter of Conductor Casing inches <br />r� r <br />Well Casing Diameter inches Total Depth O L� ft Depth to Water ft Depth of Casing ft bgs <br />DESTRUCTION SPECIFICATION <br />Sealing Material from ft bgs to C:+ C ft bgs Filler Material <br />from ft bgs to ft bgs <br />Well casing to be perforated by one of the following methods: <br />from ft bgs to ft bgs <br />❑ Mills Knife Number of cuts every ft and/or <br />❑ Explosives ❑ Detonating cord ❑ with projectiles every <br />ft ❑ without projectile <br />❑ Detonating cord and boosters ❑ with projectiles every <br />ft ❑ without projectile <br />❑ Other <br />Sealing Material C Neat Cement (94 /b bag/5-6 gal water) C Sand Cement <br />sack mixll gal water ❑ Bentonite Pellets <br />Bentonite (20% solids) - Manufacturer Spec % solids % Name <br />❑ Specs on File ❑ Specs Submitted <br />Placement Method Pumped C Free Fall -, <br />Other <br />Seal Completion' Complete with Mushroom Cap ft bgs <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 />MINIMUM � HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br />CONTRACTORS SIGNATURE _s:rF' k1- TITLE 4r P I/,,- r- / <br />AW vet <br />�9 <br />syNao, 2018 <br />H�cryo��"'Fro°UN� <br />Application Accepted By_ <br />Destruction Inspection By By <br />COMMENTS f <br />PE SC <br />Codes Ifo <br />Received <br />B <br />Amount <br />Cash Remitted <br />Date <br />Permit/ <br />Service Re uest # <br />Invoice # <br />Well ID# <br />p 10 <br />_ 2 <br />Zq <br />1700353 ?) <br />EHD 43-08 <br />10/5/07 <br />WELL DESTRUCTION PERMIT <br />