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WELL DESTRUCTION PERMIT PUBLIC WATER SYSTEM ❑ Yes ❑ No SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 East Hazelton Avenue - STOCKTON CA 95205 - (209) 468-3420 Nt7N-RFFIINnARI F PFRMIT , CALL (2091953-7697 FOR INSPECTIONS i EXPIRES 1 YEAR FROMDATE ISSUED JOB ADDRESS CITY/ZIP 1 PARCEL SIZE©- USE APPLICAT ON # CROSS TREE \ APN AND OWNER U PHONE OWNER ADDRQSS. CITY/STATE/ZIP CONTRACTOR PHONE G CONT ACTOR ADDRESS CITY/STATE/ZIP C-57 WELL DRILLING LICENSE NUMBER EXPIRATION DATE PE FORATION 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 I_i(-ense 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-------- roperty_____EXISTING EXISTINGWELL CONSTRUCTION DETAILS Open Bottom ❑ 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 ft bgs Diameter of Conductor Casing _ inches Well Casing Diameter__14 M ___ inches Total Depth It Depth to Water It Depth of Casing It bgs DESTRUCTION SPECIFICATION Sealing Material from it bgs to ft bgs Filler Material from It bgs to ft bgs Well casing to be perforated by one of the following methods: from ft bgs 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 lb bag/5-6 gal water) Sand Cement e sack mixt7 gal water Bentonite Pellets Bentonite (20% solids) Manufacturer Spec % solids _% Name----.-- Specs on File Specs Submitted Placement Method Pumped Free Fall X Other 7%0,W //� Seal Completion )d Complete with Mushroom Cap �'t�f _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. K a CONTRACTORS SIGNATUR D ARTM ENT USE ON Y�� Application Accepted By __-- Uate_-��.--- Area Destruction Inspection By l C4Q J4j0 y _ Date --- Employee ID# COMMENTS – PE SC Codes Info Received By Check#/ Cash Amount Remitted Date Permit/ Service Request # Invoice # Well ID# - s 07 -1 � 4 EHD 43-08 WELL DESTRUCTION PERMIT 4/30/12