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WELL DESTRUCTION PERMIT Ic!2 ✓ A <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-REFUNDARLF PFRMIT CALL (9(19i 953-7697 FnR INCPFRTIn NC FXPIPFC 1 VFAR FRnnn nATG IQCIICn <br />JOB ADDRESS Z 3 / p <br />CITY/ZIP Lti 1 <br />CROSS STREET APN ► O <br />PARCEL SIZE ND USE APPLICATION # <br />OWNER ool <br />PHONE <br />OWNER ADDRESSCITY/STATE/ZIP, <br />% <br />CONTRACTOR d <br />PHONEZ40 <br />CONTRACTOR ADDRESS OP.4 � �� <br />—CITY/STATE/ZIP Z&W1 <br />,,&— C-57 WELL DRILLING LICENSE NUMBER y� t Z 3 <br />EXPIRATION DATE <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 />It below ground surface (bgs) Hole Diameter inches <br />Well Conductor Casing ❑ Yes ❑ No Depth of Conductor Casing <br />It bgs Diameter of Conductor Casing _ inches <br />Well Casing Diameter_ 7 31� „ inches Total Depth 6-67 It Depth to Water_ 1 Z It Depth of Casing _._ ft bgs <br />DESTRUCTION SPECIFICATION <br />Sealing Material from _,!!� r __ft bgs to ft bgs Filler Material %�Gh-7wr� �'y>2 from _ It 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 Neat Cement (94 Ib bag/5-6 gal water) Sand Cement <br />sack mix/7 gal water Bentonite Pellets <br />Bentonite (20% solids) Manufacturer Spec % solids____ % Name <br />Specs on File Specs Submitted <br />Placement Method Pumped Fre Fall <br />Other <br />Seal Completion Complete with Mushroom Cap % ft bgs <br />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 />MI UM HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS c� <br />CONTRACTORS SIGNATURE TITLE //� DATE <br />71 PAYMENT <br />RECEIVED <br />4SEP 17 2018 <br />SAN JOAQUIN COUN- <br />E_ RTM ENT USE ONLY HE <br />&W - <br />Application Accepted By Date Area <br />Destruction Inspection By Nei—,,, 4,q Date % s/ % I Employee ID# <br />COMMENTS <br />PE <br />d es, <br />SC <br />info <br />Received <br />Check#/ <br />Cash <br />Amount at <br />Remitted <br />Permit/ <br />Service Request # <br />Invoice # <br />Well ID# <br />EHD 43-08 WELL DESTRUCTION PERMIT <br />4/30/12 <br />