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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 (209) 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS 3 01 r N. X1:45 • /tfu <br />CITY/ZIP17 f3 64 <br />'Z(p�L' <br />t APN D 0- _ <br />CROSS STREET d Ae, l.6f ,t0 <br />PARCEL SIZE (-AND USE APPLICATION If <br />OWNER 1 A <br />PHONE <br />OWNER ADDRESS IG L / af~ <br />Q <br />CITY/STATE/ZIP <br />CONTRACTOR 01wolez/111./ <br />PHONE? <br />CONTRACTOR ADDRESS O ✓ A/'/ O <br />CITY/STATE/ZIP AP -0 <br />! �CQ bG' �/7 / S 3 <br />�j <br />&--C-57 WELL DRILLING LICENSE NUMBER 73 / /P <br />EXPIRATION DATE F- 3.1 - i g <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 Iry ❑ Pit Well P— active ❑ 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 9' ravel Pack ❑ Uneased ❑ Other <br />Well Log copy attached ❑ Yes Grout Seal ❑ No ❑ Yes <br />It below ground surface (bgs) Hole Diameter _ inches <br />Well Conductor Casing ❑ vas ❑ No Depth of Conductor Casing _ <br />___fl 1--, Diameter of Conductor Casing _ _ inches <br />Well Casing Diameter_ 6- —inches Total Depth / py . It Depth to !^later_ � ZIt Depth of Casing _ /Oy_ ft bgs <br />DESTRUCTION SPECIFICATION `/ <br />42 f ft bgs to �[ft bgs Filler Material <br />Sealing Material from - /42f <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 It arid/or _ <br />❑ Explosives ❑ Detonating cord ❑ with projectiles every <br />ft ❑ without projectile <br />❑ Detonating cord and boosters ❑ with projectiles every <br />_ It ❑ without projectile <br />❑ Other <br />_ <br />Sealing Material Neat Cement (94 lb bag/5-6 gal water) Sand Cement <br />sack mix17 gal water A41re—ntonite i`)ellets <br />Benionite (20% solids) Manufacturer Spec % solids___ °'o Name <br />1-1 Specs on Fite Specs Submitted <br />Placement Method Pumped c._Eree Fall <br />Other <br />Seal Completion Complete with Mushroom Cap _ ._ ft bgs 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 Ii-, COMPLIANCE WITH ALL <br />WORKERS COMPENSATION L711MUM <br />S. D r <br />2k*M� OWR,DVANCE NOTICE REQUIRED FOR INSPECTIONS <br />Application Accepted By _ <br />Destruction Inspecon By <br />f <br />COMMENTS 10-64,0 <br />ZC, <br />EP FITMENT USE O1Y <br />c <br />_ Date <br />DateCA <br />i <br />ti✓1 <br />Area �s <br />Employee I # ,r46WW --- <br />PE <br />SC <br />Check#/ <br />Amount <br />Date <br />Permit/ <br />Invoice # <br />Well ID# <br />Code <br />Info <br />Remitted <br />Service.Rpqyest # <br />4Received <br />EHU 43-08 .� <br />f 1,y4f. 00 WELL DESTRUCTION PERMI I- <br />4/30/12 <br />r <br />