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WELL DESTRUCTION PERMIT P t/ • PUBLIC WATER SYSTEM ❑ Yes ❑ No SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 East Hazelton Avenue - STOCKTON CA 95205 - (209) 468-3420 AIl1NI_Dno1K1neo1 r DooRAiT rel I Ignm Qri'3-7F,Q7 Fnn INCPFf:TInNS FXPIRFS 1 YEAR FROM DATE ISSUED ----- ------------ - ------ JOB ADDRESS(, O t / CITY/ZIP CROSS STREET APN 5 50 Sly 4) Z PARCEL SIZE LAND USE APPLICATION # � OWNER -// •1 / T L PHONEyo 2- - / eezl 5 OWNER ADDRESSA?n CITY/STATE/ZIP {Il•/Oai11 CA_ �f366 CONTRACTOR G9/1V //'A c� NC PHONE 7 S- ev 2 L v 0d • O CONTRACTOR ADDRESS J CITY/STATE/ZIP C['e aC K / 3 8d 13 C-57 WELL DRILLING LICENSE NUMBER / /2 , � EXPIRATION DATE J--31-1 PERFORATION CONTRACTOR PHONE PERFORATION CONTRACTOR ADDRESS CITY/STATE/ZIP ❑ 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 Wellactive ❑ 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 B1,<,ravel Pack ❑ Uncased ❑ Other Well Log copy attached Yes ❑ No Grout Seal ❑ No N1 Yes /60- ft below ground surface (bgs) Hole Diameter ,?. `/ _ inches Well Conductor Casing ❑ Yes ❑ No Depth of Casing _ _ __ft bgs Diameter of Conductor Casing _ inches ,C,�,�onductor Well Casing Diameterinches Total DptN Depth to Water_ft Depth of Casing _= tt bgs DESTRUCTION SPECIFICATION � 8-e4aM,,l Sealing Material from _ d ft bgs to 7 ft.bgs Filler Material_ from 0__ft bgs to _7 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 mixll gal water A- entonite Pellets Otentonite (20% solids) Manufacturer Spec % solids __% Name_______ _ i Specs on File i Specs Submitted Placement Method Pumped Free Fall 1 Other Seal Completion Complete with Mushroom Cap _2__ ft 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 L6dNS. IM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS q, CONTRACTORS SIGNATURE �kp TITLEO�M ne- //iS DATE 7— PAY d °l E IN REC ED JUL 11 2018 SAN JOAQUIN COUNTY :.-- ENVIRONMENTAL HEALTH DEPARTMENT E PARTMENT USE ON�LY 7 Application Accepted By _ -n _ Date -/ /r / Area � Destruction Inspection By xj%,�vL /� wL9 __ Date I I ZI !s Employee ID# Ahmed COMMENTS PE SC Received Check#/ Amount Date Permit/ Invoice # Well ID# Codes Info By Cash Remitted Service Request # EHD 43-08 WELL DESTRUCTION PERMIT 4/30/12