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WELL DESTRUCTION PERMIT PUBLIC WATER SYSTFM ❑Yes []NO SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPT 1868 East Hazelton Avenue-STOCKTON CA 95205.6232-(209)468.3420 NON-REFUNDABLE PERMIT CALL CGS's I9 i tir,,i,,,'. �EXPIIRE7S/�1 YEAR FROM DATE ISSUED JOBADDRESS :/ (- 7 S4CJCK-V(�I1 +-` f CITY/ZIP L{'�(k1-j C,SA 0 CROSS STREET ,S]i fYn� Ln 1_ APN (07 S]- ( YG b -1!4—PARCEL-SLZ`E_LAND USE APPLICATION# OWNER KI 1r11rr Krc)n(-Y, nIA 1(JA1fi CI1s L-P PHONE /1 u/-�f��0 f'C OWNER ADDRESS '9�C ,'", A»S Aye S L Te M CITY/STATFJZ P I-t-1 % FC.A 5 CONTRACTOR I r r Y1 PHONE JG7 1-(Z/ /-7 9 CONTRACTOR ADDRESS t��C) 0C X 4 CRY/STATE/LP G(A CA cl S G 3 X,C-57 WELL DRILLING LICENSE NUMBER Y`h 3 5 EXPIRATION DATE_7 I-?U PERFORATION CONTRACTOR PHONE PERFORATION CONTRACTOR ADDRESS CITY/STATE/ZIP M 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 JIM 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 )0 No Grout Seal ❑ No ❑ Yes It below ground surface(bgs) Hole Diameter inches /1 Well Conductor Casing❑ Yes K No Depth of Conductor Casing ft bgs Diameter of Conductor Casing inches A Well Casing Diameter___inches Total Depth fl Depth to Water�_fl Depth of Casing ft loge A��AaNr DESTRUCTION SPECIFICATION ` v Sealing Material from !�7 bgs to_/J�0 ft bgs Filler Material from ft bgs to ft bgs .�r 1 Well casino to be Derforated by one of the followino methods: from ft bos to ft bas (, ❑ Mills Knife Number of cuts every ft and/or SAN O ?018 ❑ Explosives❑ Detonating cord ❑ with projectiles every ft 13 Without projectile AQ(f ❑ Detonating cord and boosters ❑ with projectiles every ft ❑ without projectile ly RQ O(J ❑ Other �,,N y /N��,�� N`r Sealing Materiel Neat Cement(94 lb bag/5-6 gal water) JC Sand Cement sack mix/7 gal water Bentonite Pellets DS M� Bentonite(20%solids) Manufacturer Spec%solids_% Name Specs on File Specs Submitted �NT Placement Method >C Pumped Free Fall Other Seal Completion Complete vnth Mushroom Cap 5 it bgs Complete to Existing Surface Pad I 1 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. nniNIMUvi 48 /GIJP/iJ�r'cr7AD.VANC€NOTICE REQUIRED FOR INSPECTIONS CONTRACTORS SIGNATURE - / / W �'`- TfTLE V 1 L� 1 Ct+1",e6� DATE W NG�� y Ln In V C> C,CX J•.f1 fi D E 14 T UI S E Q N L. Application Accepted By Data Area ✓�Y Destruction Inspection By Data 0 11') Employee I COMME S D'1 / 0 A- PE Sc Received Check#/ Amount Penn It/ Codes Info By- Cash Itaimitted Data 1. Service Request# Invoice# WeIIID# 1161 1 1111 Y r EHD 43-08 � ��3��L)�� //yVELLDESTRUCTION PERMIT