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WELL DESTRUCTION PERMIT f,/ PUBLIC WATER SYSTEM ❑ Yes fimo SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 East Hazelton Avenue - STOCKTON CA 95205 - (209) 468-3420 NON-REFUNDABLE PFRMIT CAI I (9(191 953-7F;97 Fna INcaFrTlnNc FYPIPFC i VCnD Cones 111ATC ln�11 Jtt3ADDRESS '73D L'cic'- CITY/ZIP J' /;--GOAT //A�� CROSS STREET uleA / F APN f /n 7d � RCEL SIZE 6 LAND USEAPPLICATION # a (L)WNER �% � 5P- O HONE �0NJ/zKdo OWNER AD RESS_ 1 �� /%%/i(�,CJ �_ �2� CITY/STATE/ZIP ZV_A&Z5a1A e*+ CONTRACTOR_ PHONE ` �1`�� CONTRACTOR ADDRESS Z CITY/STATE/Z]P �7 VC-57 WELL DRILLING LICENSE NUMBER (9 try/, EXPIRATION DATE 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 _0 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 EXISTING WELL CONSTRUCTION DETAILS )v 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 Ca ing � ft bgs f Diameter of Conductor Casing inches Well Casing Diameter /a inches Total Depth t Depth to Water_' ft Depth of Casing _ __ ft bgs DESTRUCTION SPECIFICATION 2 uc k5 Sealing Material frombgs to ft bgs Filler Material from ft bgs to ft bgs Well casing to be perforated by one of the foll Ing methods: from -__ _ ft bgs to ft bgs ❑ Mills Knife Number of cuts every ft and/or ❑ Explosives ❑ Detonating cord Elwith 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) Sand Cement sack mix/7 gal water -W Bentonite Pellets Bentonite (20% solids) Manufacturer Spec % solids--% Name I Specs on File Specs Submitted Placement Method Pumped V Free Fall - Other 614,C Seal Completion Complete with Mushroom Cap ft bgs omplete 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. y8 MIN v U VANCE NOTICE REQUIRED FOR INSPECTIONS CONTRACTORS SIGNATURE TITLE /%i'� ` DATE Xx Application Accepted By ' Destruction Inspection,By :NTS idL v t � _ AYM _ RECE,�Nr iE ED 00 AUG 15 2018 E/ROQIJ//V N� ....... ..j _ . H�ALTFI DEPA, A 1 .._. PARTMENT USE ONQL, Date �[ Date l � 1 le UA /) k /.11-niI Area t 1149 Employee ID# PE Codes SC Info Received c B Cash Amount emitted ate Permit/ Service Request # Invoice # Well ID# EHD 43-08 cV,it t'15 VVT_10W, 1/ p5� "IV6 5 V, YA_Cr_0_/ WELL DESTRUCTION PERMIT 4/30/12