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WELL DESTRUCTION PERMIT <br /> PUBLIC WATER SYSTEM ❑Yes ❑ No <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 600 E MAIN STREET-STOCKTON CA 95202 - (209)465-3420 <br /> NON-REFUNDABLE`PERMIT CALL 209)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS1h`]�r!� 1 CITY/ZIP "/l�r , <br /> CROSS STREET f O� CILN. APN L, " ) "� J PARCEL SIZE LAND U E APPLICATION# o <br /> OWNER i PHONE p L)`L <br /> �l <br /> OWNER ADDRESS CITY/STATE/ZIP <br /> CONTRACTOR /Y[7'X 6,,,4_ �"` <br /> �0_<s 4 - �Y PHONE 23 - L� <br /> CONTRACTOR ADDRESS PC �(J� L 7J CITY/STATE/ZIP <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 >Cf 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 •>Z�,No Grout Seal ❑ No X Yes ft below ground surface(bgs) Hole Diameter inches <br /> Well Conductor Casing ❑ Yes IIQI�No Depth of Conductor Casing ft bgs Diameter of Conductor Casing inches <br /> Well Casing Diameter inches Total Depth ft Depth to Water, ft Depth of Casing ft bgs <br /> DESTRUCTION SPECIFICATION n <br /> ` <br /> Sealing Material from ft bgs to Ire ft bgs Filler Material from ft bgs to ft bgs <br /> Well casing to be perforated by one of the following methods: from ft bgs to ft bgs <br /> ❑ Mills Knife Number of cuts every ft and/or <br /> ElExplosives ❑ Detonating cord ❑ with projectiles every ft ❑ without projectile <br /> ❑ Detonating cord and boosters ❑ with projectiles every ft ❑ without projectile <br /> ❑ Other <br /> Sealing Material Neat Cement(94 lb bag/5-6 gal water):-) Sand Cement sack mix17 gal waterBennttoniite Pellets <br /> Bentonite(20%solids) Manufacturer Spec%solids % Name Specs on File Spe�'sufiritited <br /> Placement Method 'N, Pumped Free Fall (Other <br /> Seal <br /> Seal Completion Complete with Mushroom Cap �CF�I fFbg�t IT <br /> Complete to Existing Surface Pad <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT TAE 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 /> MIN U y OUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br /> CONTRACTORS SIGNATURE �� TITLE 0 4JI DATE `J J <br /> Wv <br /> Sk- <br /> E XWEI <br /> EPARTMENT USE ONLY () l 9 <br /> Application Accepted Bygia ��� Date b ` Area <br /> Destruction Inspection ByDate / Employee ID#_LA-, <br /> C MMENTS y <br /> 4-21 �2r-- n <br /> PE SC Received heck Amount Permit/ <br /> Codes Info Cash Remitted Date Service Request# Invoice# Well ID# <br /> EHD 43-08 WELL DESTRUCTION PERMIT <br /> 10/5/07 <br />