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WELL DESTRUCTION PERMIT PUBLIC WATER SYSTEM ❑ Yes ❑ No SAN JOAOUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 East Hazelton Avenue - STOCKTON CA 95205 - (209) 468-3420 NON-REFUNDARLE PERMIT CALL (2091 953-7697 Fr1R INSPFCTIONS EXPIRES 1 YFAR FROM DATF ISiStIFn JOB ADDRESS`�SGN r CITY/ZIP (, CROSS STREET ` /L V OC,, APN �O3 -2,20-01 //7G(�/0%% PARCEL SIZE 410 LAND USE APPLICATION # OWNER L11PA4d/eu r �LJ`�IIC /YL-"O{%r 4hla,Q rrPH0NE -�/'-45 -'!7 OWNER ADDRESS ��oS9� bJ . LI �u • CITY/STATE/ZIPn�L�/�� c�Di�J e� CONTRACTOR no PHONE 'Z90 - LL // J-T� CONTRACTOR ADDRESS lu /�l �L CITY/STATE/ZIP WQ�� . �v� 9sds �7 XC-57 WELL DRILLING LICENSE NUMBER �7DO��J EXPIRATION DATE PERFORATION CONTRACTOR PHONE PERFORATION CONTRACTOR ADDRESS CITY/STATE/ZIP Idd- ,W 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 Expiration Date REASON FOR DESTRUCTION ❑ Dry ❑ Replacement Well ❑ Caved In ❑ Pit Well ❑ Inactive Test Hole 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 ft below ground surface (bgs) Hole Diameter inches Well Conductor Casing ❑ Yes ❑ No Depth of Conductor Casing _ _ _- ft bgs Diameter of Conductor Casing inches Well Casing Diameter_, inches Total Depth It Depth to Water It Depth of Casing _ ft bgs DESTRUCTION SPECIFICATION 1 Sealing Material from _�ft bgs to 1,k0 ft bgs Filler Material_ 00 from _ ft bgs toy 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 ft and/or ❑ Explosives ❑ Detonating cord ❑ with projectiles every _ ft ❑ without projectile ❑ Detonating cord and boosters ❑ with projectiles every _ ft ❑ without projectile ❑ Other Sealing Material Neat Cement (94 lb bag/5-6 gal wafer) i-1 Sand Cement sack mix17 gal water Bentonite Pellets Bentonite (20% solids) Manufacturer Spec % solids % Name _ Specs on File Specs Submitted P.cement Method Pumped 1 Free Fall Other Seal Completion Complete with Mushroom Cap ft 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 CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION LAWS. MINIMUM 24 HOUR ADVANCE NOTIC5-REQVIRED FOR INSPECTIONS CONTRACTORS SIGNATURE TITLE !/,C� DATE t .. s - _1..., i . .. . Application Accepted By' 10 Destruction Inspection By COMMENTS l D_1C D PARTM ENT USE ON Y c Date Date A _l.. tnw0J ? , Area Ckliel Employee ID# rA PE Codes Sc Info Received B ashem Amount ttecl Date Permit/ Service Request # Invoice # Well ID# 4'' p, � I —V , . g Ai A EHD 8 m� (_CQd�� WELL DESTRUCTION PERMIT 4/30/12 D / J (J