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WELL DESTRUCTION PERMIT '/ PUBLIC WATER SYSTEM ❑Yes ❑No SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 600 E MAIN STREET-STOCKTON CA 95202 - (209)468-3420 NON-REFUNDABLE PERMIT CALL(209)953-7697 FOR IN PE ONS EXPIRES 1 YEAR FROM DATE ISSUED ^ JOB ADDRESS 30311 ' � � CITY IP -01k �fJc;�( •1 q+ CROSS STREET APN �� i�S PARCEL SIE 14'e / OWNER 1� VJ�t1L�� l /��i� ic) A Pmodcr I'O'H0NE q R 6 _ t (1,) K OWNER ADDRESS y ) )� ]� L-�'�- V CITY/STATE/ZIP E SC't/G' �' ��a �� 5 `� ; 77 _ ` CONTRACTOR G:S f I I I J . I� I J H I -�-r.%( PHONE ONTRACTOR ADDRESS ) T !`fi r CITY/STATE/ZIP I v v d-J4" -1 '/5? C-57 WELL DRILLING LICENSE NUMBER 1 (l-7 1. EXPIRATION DATE y -� PERFORATION CONTRACTOR PHONE PERFORATION CONTRACTOR ADDRESS CITY/STATE/ZIP ❑ 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 /_1 inches Total Depth ft Depth to Water q ft Depth of Casing ft bgs DESTRUCTION SPECIFICATION Sealing Material from 1 4r ft bgs to 0 ft bgs Filler Material !` h from ft bgs to 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 Elwith projectiles every f4 ❑ without projectile ❑ Other �,.,f$ Sealing Material Neat Cement(94 Ib bag/5-6 gal water)-� Sand Cement � } sack mix17 gal water ❑ Bentonite Pellets Manufacturer Spec%solids % Name Specs on File ❑ Specs Submitted Placement Method - (� Pumped ❑ Free Fall Other Seal Completion Complete with Mushroom Cap ft bgs Jt 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. rj111MUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS CONTRACTORS SIGNATURE TITLE �At 00. DATEtoy PA y° Oct JOA 9 N� y p�pq�NTgt�Y —' TMENT DE P4RTM ENT US E ON LY Application Accepted By Date w Area Destruction Inspection By /'ZJCLS et!:,•t 11 � Date 3 2 t / Employee ID#_ COMMENTS '' �.c J /! .1lC! 7<' r t L �CC� `t (r . t'.i f A �rcK: J '<.-. PE SC Received Check#/ Amount Date Permit/ Invoice# Well ID# Codes Info B ash Remitted Service Request# EHD 43-08 � WELL DESTRUCTION PERMIT 10/5/07