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WELL DESTRUCTION PERMIT PUBLIC WATER SYSTEM ❑Yes ❑No SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1668 East Hazelton Avenue-STOCKTON CA 95205 - (209)468-3420 NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED t 2 M X00 6? u.0 y� JOB ADDRESS L 3 �nn77CITY/ZIP T1�- ��yyM.f"V 'r[� - C7 CROSS STREET �1STiJ_V, L-I JN�J APN_ a,1IN' - 01�PARCEL SIZE[$``LAND USE APPLICATION# OWNER i�(� �5 LrG PHONE !J" / j,C1 JG�) 2 OWNER ADDRESS Py CITY/STATE/ZIPIfUGGE7 TC--iO CA 1135 CONTRACTOR PHONE 2DI CONTRACTOR ADDRESSug �q CITY/STATE2IP 059E� 46 W-31 /2 n q�2& A'C-57 WELL DRILLING LICENSE NUMBER J L�3 EXPIRATION DATE �/1 1 PERFORATION CONTRACTOR PHONE PERFORATION CONTRACTOR ADDRESS CITY/STATE/ZIP C-57 Well Drilling License Number Oka Expiration Date A&/IB ❑ 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 ❑ Replacement Well ❑ Caved In ❑ Pit Well ❑ Inactive Test Hale Detected/Suspected Well Water Contaminant(s) Adjacent property with contamination(Address) Known Soil/Water contaminants at adjacent property EXISTING WELL CONSTRUCTION DETAILS ❑ Open Bottom ❑ Gravel Pack Uncased ❑ Other Well Log copy attached ❑ Yes ❑ No Grout Seal ❑ No ❑ Yes_ it below ground surface(bgs) Hole Diameter_�7i inches Well Conductor Casing ❑ Yes ❑ No Depth of Conductor asing ft bgs Diameter of Conductor Casing fi / nches Well Casing Diameter inches Total Depth Depth to Watery ft Depth of Casing A ft bgs IF 04 F DESTRUCTION SPECIFICATION Sealing Material from ft bgs to _0 ft bgs Filler MaterialO NG from ft bgs to ft bgs Well rasing to be perforated by one of the following methods: ________ from_ ft bgs to it bgs ! F1 Mills Knife !_ Number of cuts every It ancilur__ ❑ Explosives ❑ Detonating cord ❑ with projectiles every ft ❑ without projectile ❑ Detonating cord and booster h projectiles every �ft ❑ without projectile ❑ OtherCJI ' e.tLcu U/�► 'r S al' g Material Neat Cement(94 lb ag/5-6 gal water) i Sand Cement _ sack mix17 gal water r1 Bentonite Pellets entonite( 0%solids) Manufacturer Spec%solids % Name i I Specs on File I Specs Submitted a ment Method I Pumped i, Free Fall Other Seal Completion Complete with Mushroom Cap It 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 CURHEN i AND ACTIVE_ WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL KERS COMPENSATION LAWS. 2��k g;� MI R DV TICS REQUIRED FOR INSPECTIONS " CONTRACT R SIG AT� TITLE QIOwI�Z DATE+so L� (� LOL/ I ; cwql ,, - YMENT qoo � .J~�� j � �� RECEIVED �nn e FEB 14 2018 Ole JOAQUIN COUNT'• Zt2 �2`Z ENVIRONMENTAL TH DEPARTMEN / D PAR 1- MENT USE ON L Application Accepted By Date Area Destruction Inspection By _ _ Date Employee ID# jIW� COMMENTS 2 3 n abl wt0.1C er x 6a "s 3 -L 9.11 a u PE SC Received ec Amount Permit/ Co es Info Cash_ emitted Date_ Service Request# Invoice# Well ID# l of-k4TO n " 2-11411F )PO X95 h EHD 43-08 V D S of �t� n S 1 �)/VELL DESTRUCTION PERMIT 4130/12 , `v Z/ J (/ U (� r� (t°✓ q . lraVr%