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C; WELL DESTRUCTION PERMIT I� ✓ j, <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 PERMIT CALL (209) 953-7697 FOR INSPECTIONS EXPIRES '1 YEAR FRnnn nATF ICCIIGn <br />JOB ADDRESS Z 3 9 r <br />CITY/ZIP <br />CROSS STREET APN _ O �� <br />PARCEL SIZE ND USE APPLICATION # <br />OWNER <br />PHONE <br />OWNER ADDRESS <br />-CITY/STATE/ZIP, 9� Q <br />• <br />CONTRACTOR <br />PHONE <br />CONTRACTOR ADDRESS f • .4 �� <br />CITY/STATE/ZIP_Z61e'l <br />C-57 WELL DRILLING LICENSE NUMBER Y4 It Z 3 <br />EXPIRATION DATE Z!9: <br />PERFORATION CONTRACTOR <br />PHONE <br />PERFORATION CONTRACTOR ADDRESS <br />CITY/STATE/ZIP <br />❑ C-57 Well Drilling <br />License Number Expiration Date <br />❑ Bureau of Alcohol, Tobacco and Firearms - Users of High Explosives <br />License Number Expiration Date <br />❑ CHP Hazardous Material Transportation for Explosives <br />License Number Expiration Date <br />❑ San Joaquin County Sheriff -Coroner Explosives Application and Permit <br />License Number Expiration Date <br />❑ California Occupational Safety Health - Blaster <br />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 ❑ Open Bottom ❑ Gravel Pack ❑ Uncased ❑ Other <br />Well Log copy attached ❑ Yes ❑ No Grout Seal ❑ No ❑ Yes _ <br />ft below ground surface (bgs) Hole Diameter inches <br />Well Conductor Casing ❑ Yes ❑ No Depth of Conductor Casing <br />ft bgs Diameter of Conductor Casing inches <br />Well Casing Diameter '7 3/y inches Total Depth 6L r it Depth to Water / Z ft Depth of Casing It bgs <br />DESTRUCTION SPECIFICATION <br />Sealing Material from _ ft bgs to _� ft bgs Filler Material l""')N2 from ft bgs to ft bgs <br />Well casing to be perforated by one of the following methods: <br />from ft bgs to ft bgs <br />❑ Mills Knife Number of cuts every _._ft and/or <br />❑ Explosives ❑ Detonating cord ❑ with projectiles every <br />ft ❑ without projectile <br />❑ Detonating cord and boosters ❑ with projectiles every <br />ft ❑ without projectile <br />❑ Other <br />Sealing Material n Neat Cement (94 Ib bag/5-6 gal water) F -i Sand Cement <br />sack mix/7 gal water 77 Bentonite Pellets <br />I ; Bentonite (20% solids) ❑ Manufacturer Spec % solids % Name <br />❑ Specs on File ❑ Specs Submitted <br />Placement Method n Pumped n Fre Falln <br />Other <br />Seal Completion i_ Complete with Mushroom Cap ft bgs <br />L 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 />HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br />CONTRACTORS SIGNATURE MI UM TITLE //w,'_� DATE�� <br />Y <br />C <br />d <br />