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WELL DESTRUCTION PERMIT PUBLIC WATER SYSTEM ❑Yes ❑No SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPT 1868 East Hazelton Avenue-STOCKTON CA 95205-6232-(209)468-3420 NON-REFUNDABLE PERMIT _ CALL 209 953-7697 FOR INs EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS I l CIT/21P 4- LCA-�.��-'f'Q 41A CROSS STREET ��- /e N� /�-1 APN �O -�'r PARCEL$IZE qj/LA�N,D USE ArP,PLICATION# �V OWNER �OO�" � PHONE !-lW/^Sa 7� OWNER ADDRESS CITYISTATFJZIP L;l ndenf If- 9S�-3C CONTRACTOR 1 kV/4AXtr Die;//cia'/Z.ve. PHONE Z_09 '8k7-3s-Jy CONTRACTOR ADDRESS I-10l3rx Co 4 CITYISTATEIZIP L/nd l x),CA-9OL3 6 C-57 WELL DRILLING LICENSE NUMBER 377923 EXPIRATION DATE 7-3I-/9 PERFORATION CONTRACTOR PHONE PERFORATION CONTRACTOR ADDRESS CITYISTATEIZIP ❑ 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 9 Inactive ❑ Test Hole Detected/Suspected Well Water Contaminants) ✓7L/u Adjacent property with contamination(Address) Known Soil/Water contaminants at adjacent property �yw EXISTING WELL CONSTRUCTION DETAILS 10 Open Bottom ❑ Gravel Pack ❑ Uncased ❑ Other Well Log copy attached ❑ Yes If No Grout Seal ❑ No ❑ Yes___ft below ground surface(bgs) Hole Diameter inures Well Conductor Casing❑ /Yes ® No Depth of Conductor Casing ft bgs Diameter of Conductor Casing inches i Well Casing Diameter J#" inches Total Depth264 ft Depth to Water. ��/ It Depth of Casing 11Ci ft bgs DFSTRIVRON SPECIFICATION Sealing Material from It bgs to ftbgs Filler Material aur _ from 2�l�ft bgs to 4XI 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 0111 Sealing Material Neat Cement(94 lb bag/5.6 gal water) Sand Cement sack mix/7 gal water Bentonite Pellets Bentonite(20%solids tacturer Spec%solids_% Name Specs on File Specs Submitted Placement Method Pum Free Fall Other Seal Completion Complete with Mushroom Cap ;i C 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. R:9! IAr,i7DA V�7; NOTICE REP ! rl cnR(� 01= N CONTRACTORS SIGNATURE TITLE WE - -- - - --- - Fz�CEN O AQU1N IINN SAN JO NTAL N EN JIRONM TMENT HEALTH DEI' D ARTMENT USE ONL Application Accepted By Date Destruction Inspection By Date L Employee 1 (�✓�" `'] / COMMENTS �I 1N,t t. tiO�.L PE SC Received Ch Amount Permit/ ((�� Codes Info B emitted Date Service Re uest# Invoice# Well ID# �Xt\ �✓y i U (41 L �i i 1 wt1 EHD 43-08 WELL DESTRUCTION PERMIT 10/5/07