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WELL DESTRUCTION PERMIT I � ✓ • <br />PUBLIC WATER SYSTEM ❑ Yes ❑ No <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />1868 East Hazelton Avenue - STOCKTON CA 95205 - (209) 468-3420 <br />IVUIV-REFUNDABLE PERMIT CALL (21.11y) 9bJ-/bVf FOR INSPECTIONS tAF'IHtb 1 YEAR t -ROM DATE ISSUED <br />JOB ADDRESS C J� /�� `�/C /Z �C / <br />,,sir <br />CITY/ZIP �Lrr/1Jf <br />elo Z <br />/ <br />CROSSSTREET 1 C GE's �� APN #715_010 <br />PARCEL SIZE LAND USE APPLICATION # <br />OWNER //kL) 1 00�' /_i7 <br />PHONE <br />7 �Z <br />OWNER ADDRESS 13 % <br />CITY/STATE/ZIP <br />�75SYO <br />( � <br />PHONE -7 <br />7 Z 79CONTRACTOR <br />CONTRACTOR ADDRESS <br />CITY/STATE/ZIP <br />C-57 WELL DRILLING LICENSE NUMBER A-V %L7 7[, <br />EXPIRATION DATE <br />PERFORATION CONTRACTOR <br />PHONE <br />PERFORATION CONTRACTOR ADDRESS <br />CITY/STATE/ZIP <br />❑ C-57 Well Drilling <br />License Number <br />Expiration Date <br />❑ Bureau of Alcohol, Tobacco and Firearms - Users of High Explosives <br />License Number <br />Expiration Date <br />❑ CHP Hazardous Material Transportation for Explosives <br />License Number <br />Expiration Date <br />❑ San Joaquin County Sheriff -Coroner Explosives Application and Permit <br />License Number <br />Expiration Date <br />❑ California Occupational Safety Health - Blaster <br />License Number <br />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 51Open Bottom ❑ Gravel Pack ❑ Uncased ❑ Other P 1111— <br />Well Log copy attached ❑ Yes ❑ No Grout Seal ❑ No ❑ Yes ft below ground surface (bgs) Hole Dianiftwo�e_-� INes <br />ing �WD <br />Well Conductor Casing ❑ Yes ❑ No Depth of Conductor Casing 1t bgs Diameter of Conductor Cashes <br />Well Casing Diameter _lz—' inches Total Depth % Zie -ft Depth to Water % 2 ft Depth of Cq" . It bgs <br />DESTRUCTION SPECIFICATION SAN <br />Sealing Material from �ft bgs to ' S ft bgs Filler Material from jp �(iliv Cgs <br />Well casing to be perforated by one of the following methods: _ from ft bgs ib''�'rH <br />❑ Mills Knife Number of cuts every It and/or M NT <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 Ib bag/5-6 gal water) Sand Cement sack mix/1 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 ?i�Ci It bgs 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. /.,P <br />MINIMUM UR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br />CONTRACTORS SIGNATURE TITLE ` 3�`� `, "may- DATE <br />PE SC <br />Info <br />Received <br />B <br />eck <br />s <br />Amount <br />Remitted <br />Dote <br />Permit/Codes <br />ServiceRe uest # <br />Invoice # <br />Well ID#' <br />cc <br />D7 <br />EHD 43-08 WELL DESTRUCTION PERMIT <br />4/30/12 <br />r� <br />Y <br />