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• WELL DESTRUCTION PERMIT <br />PUBLIC WATER SYSTEM ❑ Yes ❑ No <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 East Hazelton Avenue - STOCKTON CA 95205 - (209) 468-3420 <br />NON-REFUNDABLE PERMIT CALL (2091953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE IssuFD <br />JOB ADDRESS C J ^ <br />CITY/ZIP <br />Received <br />CROSS STREET � APN <br />n <br />PARCEL SIZE L <br />AND USE APPLICATION # <br />OWNER. lf(-rV- /7-F <br />PHONE <br />OWNER ADDRESSCITY/STATE/ZIP <br />Info <br />CONTRACTOR 14L p tS ' �• L' _ 6 <br />PHONE ?��� <br />3Z7"f ZG7 <br />j <br />CONTRACTOR ADDRESS /� • Li /fin / ,6 J! r. <br />CITY/STATE2IP <br />f'i //> <br />f['C-57 WELL DRILLING LICENSE NUMBER 7 2i <br />EXPIRATION DATE <br />/ .By <br />VI ✓ <br />PERFORATION CONTRACTOR <br />PHONE <br />�r <br />1 <br />PERFORATION CONTRACTOR ADDRESS <br />CITY/STATE/ZIP <br />❑ C-57 Well Drilling <br />License Number <br />Expiration Date <br />❑ Bureau of Alcohol, Tobacco and Firearms - Users of High Explosives <br />License Number <br />Expiration Date <br />❑ CHP Hazardous Material Transportation for Explosives <br />License Number <br />Expiration Date <br />❑ San Joaquin County Sheriff -Coroner Explosives Application and Permit <br />License Number <br />Expiration Date <br />❑ California Occupational Safety Health - Blaster <br />License Number <br />Expiration Date <br />REASON FOR DESTRUCTION ❑ Dry ❑ Replacement Well ❑ Caved In ❑ Pit Well <br />❑ 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 ❑ <br />Uncased ❑ Other _ <br />Well Log copy attached ❑ Yes ❑ No Grout Seal ❑ No ❑ Yes <br />ft below ground surface (bgs) Hole Diameter inches <br />Well Conductor Casing ❑ Yes ❑ No Depth of Conducto Casing <br />ft b s Diameter of Conductor Casing inches <br />Well Casing Diameter_ fi inches Total Depth ___ft Depth to Water_ ft <br />Depth of Casing ft bgs <br />DESTRUCTION SPECIFICATION <br />Sealing Material from ft bgs to _ ft bgs Filler Material <br />��c s'r�e <br />from Ll '-r ft bgs to 3 ft bgs <br />Well casing to be perforated by one of the following methods: <br />from <br />ft bgs to ft bgs <br />❑ Mills Knife Number of cuts every _ft and/or <br />❑ Explosives ❑ Detonating cord ❑ with projectiles every <br />ft <br />❑ without projectile <br />❑ Detonating cord and boosters ❑ with projectiles every <br />ft <br />❑ without projectile <br />❑ Other <br />Sealing Material Neat Cement (94 Ib bag/5-6 gal water) Sand Cement <br />sack <br />mix/7 gal water ot-Bentonite Pellets <br />Bentonite (20% solids) Manufacturer Spec % solids % Name _ <br />Specs on File Specs Submitted <br />Placement Method Pumped Free Fall <br />Other <br />Seal Completion,,C, Complete with Mushroom Cap _ It bgs Complete to Existing Surface Pad <br />I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE 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 />7V <br />M ILN UR ADVANCE NOTICE REQUIRED FO INSIONS <br />CONTRACTORS SIGNATURE TITLE �� i��1' C DATE Z-5'1 <br />Application Accepted By <br />Destruction Inspection By <br />COMMENTS <br />D PARTMENT USE ONLY,(/�(� <br />_ Date v Area <br />Date�o Employee I # <br />PE <br />SC <br />Received <br />Amount <br />Permit/ <br />Codes <br />Info <br />Cash <br />Remitted <br />Date <br />Service Request # <br />Invoice # <br />Well ID# <br />/ .By <br />VI ✓ <br />�r <br />1 <br />�/ <br />+ <br />EHD 43-08 WELL DESI RUCTION PERMIT <br />4/30/12 <br />