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WELL DESTRUCTION PERMIT F <br /> PUBLIC WATER SYSTEM ❑� 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 FROM DATE ISSUED <br /> JOB ADDRESS / CITY/ZIP <br /> CROSS STREETt4WW 0 a 4,06 01 1p� <br /> PARCEL SIZE 4*"'-I.AND USE APPLICATION# <br /> OWNER 'f �L�LJ�/G� �L�I�II�) %HONE 790 _J?7,PI) <br /> OWNER ADDRESS �/�/'i`�' CITY/STATE21QP ® <br /> CONTRACTOR ` PHONE /g!/— <br /> CONTRACTOR ADDRESS- CITY/STATE/ZIP <br /> AlC�/il e ll' <br /> C-57 WELL DRILLING LICENSE NUMBER EXPIRATION DATE <br /> PERFORATION CONTRACTOR PHONE <br /> PERFORATION CONTRACTOR ADDRESS CITY/STATE/ZIP <br /> ❑ C-57 Well Drilling License Number Expiration Date <br /> ❑ Bureau of Alcohol,Tobacco and Firearms-Users of High Explosives License Number Expiration Date <br /> ❑ CHP Hazardous Material Transportation for Explosives License Number Expiration Date <br /> ❑ San Joaquin County Sheriff-Coroner Explosives Application and Permit License Number Expiration Date <br /> ❑ California Occupational Safety Health-Blaster License Number Expiration Date <br /> REASON FOR DESTRUCTION ❑ Dry ❑ Replacement Well ❑ Caved In ❑ Pit Well Inactive ❑ Test Hole <br /> Detected/Suspected Well Water Contarninant(s) <br /> Adjacent property with contamination (Address) <br /> Known Soil/Water contaminants at adjacenttproperty <br /> EXISTING WELL CONSTRUCTION DETAILS JX Open Bottom ❑ Gravel Pack ❑ Uncased ❑ Other <br /> Well Log copy attached ❑ Yes ❑ No Grout Seal ❑ No ❑ Yes It below ground surface(bgs) Hole Diameter inches <br /> Well Conductor Casing ❑ Yes ❑ No Depth of Conductor Casing _ ft bgs Diameter of Conductor Casi �rinches <br /> Well Casing Diameter____ inches Total Depth�ft Depth to Water "_Y-221 Depth of Casift INT., <br /> DESTRUCTION SPECIFICATION �77 qq 11'' <br /> Sealing Material from _�_> _ ft bgs to ___16 ft bgs Filler Material from _____It bg5t06_ __ �,(��ys <br /> Well casing to be perforated by one of the following methods: from ft bgs t �ft b (J <br /> icy) N <br /> D Mills Knife Number of cuts every ft and/or COU" <br /> 0 Detonating cord 0 with projectiles every ft 0 without <br /> ❑ Explosives ❑ Detonating cord and boosters ❑ with projectiles every ft ❑ without projectile D p NT <br /> ❑ Other__ _ <br /> Sealing Material Neat Cement(94 lb bag/5-6 gal water) Sand Cement sack mixll gal water I-V Bentonite Pellets <br /> Bentonite(20%solids) Manufacturer Spec%solids % Name Specs on File Specs Submitted <br /> Placement Method Pumped >' Free Falls i Other <br /> Seal Completion Complete with Mushroom Cap --- �t 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. <br /> M;;T=;;�=ITLE <br /> RED FOR INSPECTIONS <br /> CONTRACTORS SIGNATURE S'�� DATE <br /> o <br /> I s . <br /> j <br /> I It <br /> t. ... t <br /> I. <br /> ?J� <br /> DEPARTMENT USE ONLY L / <br /> Application Accepted By_ Date 3 y�0 Area <br /> Destruction Inspection By/l/Gt � Date ,1 rli Employee ID# <br /> ven <br /> COMMENTS C. O O O 9 _71r3 7 C44ly( h Ad IK 5 C,(M Al A-A4, <br /> PE SC Received heck Amount Permit/ <br /> Codes Info B s Remitted Date Service Request# Invoice# Well ID# <br /> y 3-3� I �' I � 2S� '.� 71 <br /> EHD 43-08 WELL DESTRUCTION PERMIT <br /> 4/30/12 <br />