WP0038388 - Laserfiche WebLink

Home Browse Search

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 1fYEAR FROM DATE ISSUED / s JOB ADDRESS O �J' /t p q CITY/ZIP PKe—c-00 CROSS STREET D /8 Mi'ts Lc dO�P�r�P�N 9.2 7O3PARCEL SIZA41AND3USE APPLICATION # `2<2 OWNER L .OK v�n�aRes /-" PHONE �' 7/60- p[2,,r-0'47 % OWNER ADDRESS / 5V0 A C C � w w `� CITY/STATE21P,0CC'1C// 4,1 ,# T,5'&d' CONTRACTOR 't ✓ N l - A0 B A e_ ' PHONE 2 O 77 �i/2 CONTRACTOR ADDRESS3O ST CITY/STATE21P 7c-,,eBF q "� ► / y �d Q j�/C-57 WELL DRILLING LICENSE NUMBER G/3 y d, 2- / _ 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 Expi REASON FOR DESTRUCTION ❑ Dry ❑ Replacement Well ❑ Caved In ❑ Pit Well 2+4gactive Detected/Suspected Well Water Contaminant(s) Adjacent property with contamination (Address) Known Soil/Water contaminants at adjacent property EXISTING WELL CONSTRUCTION DETAILS ❑ Open Bottom Lr Gravel Pack ❑ Uncased ❑ Ide IRON A t r Well Log copy attached ❑ Yes Er' Grout Seal ❑ No i Yes _ _ _ ft below ground surface (bgs) Hole Diame ,&PARTA,E[y7inches Well Conductor Casing ❑ Yes EIoNo Depth of Conductor Casing It bgs Diameter of Conductor Casing inches Well Casing Diameter__ inches Total Depth _420� It Depth to Water_ Jam_ ft Depth of Casing ft bgs DESTRUCTION SPECIFICATION Sealing Material from _ O� It bgs to _ `�_r _ It bgs Filler Material L u�K3rJ10/L _ from V0 , It bgs to ft bgs Well casing to be perforated by one of the following methods: ___.___ from ft bgs to__ ft bgs ❑ Mills Knife Number of cuts every It and/or _ ❑ Explosives ❑ Detonating cord ❑ with projectiles every ft ❑ 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 Cement Bentonite (20% solids) Manufacturer Spec % solids % Name Placement Method r Pumped i Free Fall Other Seal Completion Complete with Mushroom Cap �K_� _____ ft bgs mix/7 gal water Bentonite Pellets I Specs on File Specs Submitted Complete to Existing Surface Pad I HEREBY CERTIFY THAT 1 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. CONTRACTORS SIGNATURE N Application Accepted By _ Destruction Inspection By COMMENTS 7MI M M 2 UR ADVANCE NOTICE REQUIRED FOR INSPECTIONS / Q TITLE e'2 AS,i / DATE t10 DE ARTMENT USE ON Y Date C" Area S C Date_ Employee ID# PE Codes SC Info Received B PKe—c-00 Amount ern to Date Permit! Service Request # Invoice # Well ID# EHD 43-08 WELL DESTRUCTION PERMIT 4/30/12 T