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WELL DESTRUCTION PERMIT P <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 PERMIS CALL (2091953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS CITY/ZIP <br />CROSS STREET + APN '^ f ' �/� yPARCEL S/ZE "-LAND APPLICATION # <br />Y <br />OWNER P1--1t106,,2cl 41, V t U�HONEEjLJ C7 % <br />— ZZ -570 <br />OWNER ADDRESS CITY/STATE/ZIP �t <br />CONTRACTOR .�� PHONE -30 /— ,?j'' <br />CONTRACTOR ADDRESS Lf GG.� //yfL–_L�C)C /p�{ CITY/STATE/ZIP <br />C-57 WELL DRILLING LICENSE NUMBER�EXPIRATION DATE TJ <br />PERFORATION CONTRACTOR PHONE <br />PERFORATION CONTRACTOR ADDRESS CITY/STATE/ZIP <br />❑ C-57 Well Drilling License Number Expiration Date <br />❑ Bureau of Alcohol, Tobacco and Firearms - Users of High Explosives License Number Expiration Date <br />❑ CHP Hazardous Material Transportation for Explosives License Number Expiration Date <br />❑ San Joaquin County Sheriff -Coroner Explosives Application and Permit License Number Expiration Date <br />❑ California Occupational Safety Health - Blaster 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 1�0 Open Bottom ❑ Gravel Pack ❑ Uncased ❑ Other <br />Well Log copy attached ❑ Yes ❑ No Grout Seal ❑ No ❑ Yes _ It below ground surface (bgs) Hole Diameter} inches <br />Well Conductor Casing ❑ des LJ No Depth of Conductor Casing _ _ ft bgs Diameter of Conductor Casing y nches <br />Well Casing Diameter_ inches Total Depthmp__ R Depth to Water It Depth of Casing It bgs <br />DESTRUCTION SPECIFICATION <br />Sealing Material frombgs tl� Ow Filler Material from _ ft bgs to ft bgs <br />Well casing to be perforated by one of the following methods: from ft bgs to ft bgs <br />❑ Mills Knife Number of cuts every ft and/or <br />❑ Explosives ❑ Detonating cord ❑ with projectiles every ft ❑ without projectile <br />❑ Detonating cord and boosters ❑ with projectiles every ft ❑ without projectile <br />❑ Other <br />Sealing Material Neat Cement (94 lb bag/5-6 gal water) Sand Cement sack mix/7 gal water Bentonite Pellets <br />Bentonite (20% solids) Manufacturer Spec % solids__-__-.% Name Specs on File Specs Submitted <br />Placement Method Pumped Free Fall Other <br />Seal Completion Complete with Mushroom Cap ft bgs V 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 />'ANCE NOTICE REQUIRED FOR INSPECTIONS <br />CONTRACTORS SIGNA <br />DE ARTMENT USE ON Y <br />Application Accepted By _ _ Date Area <br />Destruction Inspec,>ion By Wate_Z� Employee ID# <br />COMMENTS �, t <br />PE <br />SC <br />Received <br />Check#/ Amount <br />Date <br />Permit/ <br />Invoice # <br />Well ID# <br />Codes <br />Info <br />B <br />RemittedDate <br />Service Request # <br />05 <br />Is <br />EFID 43-08 WELL DESTRUCTION PERMIT <br />4/30/12 <br />rn <br />-i <br />m <br />A <br />