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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 NnPJ-PPPIINr1ARl F PFRu11T rel 1 I?AQ1 QR'1_7AQ7 Fnc INcIDPITInMQ FYPIRFC 9 VcAo P -11A nATC Iccllcn JOB ADDRESS �111`` $4 Ir'7 CITY/ZIP • CROSS STREET A P N 23-Y' 10 0 - V PARCEL SIZE 21. LAND USE APPLICATION # OWNER / 0 (i Q PHONE QC"R�1G OWNER ADDRESS J r +" c �,/ CITY/STATE/ZIP V 4/ J Jd 4 C/ r y? ?W—enc n CONTRACTOR / A� "A 1. A PHONE /�� CONTRACTOR ADDRESS 3.049 J K ! �}'' (/� CITY/STATE/ZIP / L(Q A0G ` ` J4 0347 f (�, ✓L:-57 WELL DRILLING LICENSE NUMBER ; 'L y Z 1 EXPIRATION DATE PERFORATION CONTRACTOR C.RQ Op _ PHONE P PERFORATION CONTRACTOR ADDRES / %O O K 17/ 0 ,_— r� �J Q %� CITYISTATE/ZIP WBOI� / /T'N L'# 0`C-57 Well Drilling License Number 413 V` 2 % 1 Expiration Date —'Bureau of Alcohol, Tobacco and Firearms - Users of High Explosives License Number - %%i O/llkxpiration Date 2 ✓ CHP Hazardous Material Transportation for Explosives License Number / %7 :2 & / 7 Expiration Date % /3 /San Joaquin County Sheriff -Coroner Explosives Application and Permit License Number / 7 — O 2 Expiration Date California Occupational Safety Health - Blaster License Number 1 O t Expiration Date Z A REASON FOR DESTRUCTION ❑ Dry ❑ Replacement Well aved In ❑ Pit Well nactive ❑ 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 19"'No Grout Seal ❑ No ❑ Yes 0 below ground surface (bgs) Hole Diameter SAS, 4)w;A � Well Conductor Casing ❑ Yes No Depth of Conductor Casing ft bgs Diameter of Conductor Casing IRghe Well Casing Diameter��_ inches Total Depth �ft Depth to Water_ft Depth of Casing DEtiTRIICTION SPECIFICATION Sealing Material from O 6 0 ft bgs to / 0 _ ft bgs Filler Material C 0 C'<t i1t from b'D , It bgs to It bgs Well casing to be perforated by one of the following methods: from 84 ft bgs to ��' _ It b s �p� '�0 ❑ Mills Knife Number of cuts every It and / or 1� r Explosives ❑ Detonating cord ❑ with projectiles every /0 ft El without projectile /V Deto ting cord and b sters ❑ with projectil ev ry ap Q without projectile A� �or�szs 7O � ❑ Other .�.t,l�s a 9e if IP/Q I ✓i Sealing Material Neat Cem t (94 /b bag / 6 gal water) ✓Sand Cem t A% 3 sack mix / 7 gal water Bentonite Pellets Bentonite (20% solids) Manufacturer Spec % solids % Name Specs on File Specs Submitted Placement Method %J�dmped Free Fall Other , Seal Completion Complete with Mushroom Cap J 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. M MU 4 ADVANCE NOTICE REQUIRED FOR � INSPECTI`O7�NSS /f Q CONTRACTORS SIGNATURE TITLE4 /W eO / VY - DATE Z `—/! le Application Accepted By - Destruction Inspection By COMMENTS f /11 a Al 0Ile A I �T �vp® 22 h,�s 4vv� III TV pARTTAL MENT D6.P RTMENT USE ON Y Date Area DateZ- Employee ID# EHD 43-08 WELL DESTRUCTION PERMIT revised 4/14/18