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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 NON-REFUNDABLE PERMIT CALL (209) 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS CITY/ZIP CROSS STREET A P N i D _PARCEL SIZE i AND USE APPLICATION # Amount emitted Date OWNER PHONE OWNER ADDRESS O CITY/STATE/ZIP CONTRACTOR < PHONE L Sl CON RACTOR ADDRESS CITY/STATE/ZIP C-57 WELL DRILLING LICENSE NUMBER EXPIRATION DATE —5/1q, ��T�� 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 ❑ CNP 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 V 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 Cl Gravel Pack ❑ Uncased Other Well Log copy attached ❑ Yes 0 No Grout Seal ❑ No 17 Yes __- ft below ground surface (bgs) Hole Diameter _ -- __— inches Well Conductor Casing Yes ❑ No Depth of Conductor Casing it bgs Diameter of Conductor Casing inches Well Casing Diameterinches Total Depth ! �—_ ft Depth to Wale! -_ _ ft Depth of Casing It bgs DESTRUCTION SPECIFICATION Sealing Material from _ V ft bgs to _ ft bgs Filler Material ..--_ __ ______.___ ____ from _ ft bgs to It 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 arid/or ❑ Explosives ❑ Detonating cord ❑ with projectiles every It ❑ without projectile ❑ Detonating cord and boosters ❑ with projectiles every It ❑ without projectile ❑ Other_ Sealing Material Neat Cement (94 Ib bag/5-6 gal water) Sand Cemr" nt ! _ _ sack mix/7 gal water Bentonite Pellets Bentonite (20% solids) Manufacturer Spec % solids __ _ _ a Name _ _ .._______ _____ Secs on File Specs Submitted &l%GA" Placement Method Pumped Free FII IQ Other U� Seal Completion �/ Complete with Mushroom Cap "��J.�___ l 1.+gs 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. r NIMUM O UR ADVAN OTICE REQUIRED OR INSPECTIONS CONTRACTORS SIGNATURE TITLE DATE L 16 low PQV\N CP�- Sp` E�1 N p�ppgTME�T' A TMENT USE ON Y Application Accepted ByA/A---- - Date / — Area Destruction Inspection By fJl ..__ Date Employee ID# COMMENTS t. -L c��l S r VAC �Gz�j CP�vrtO-r/c PE Codes Sc Info Received B Check#/ Cash Amount emitted Date Permit/ rvice Request # Invoice # Well ID# 1-� -� EHD 43-08 WELL DESTRUCTION PERMIT 4/30/12