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WELL DESTRUCTION PERMIT <br /> PUBIJCWATER SYSTEM ❑Yes;KN. <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPT 1868 East Hazelton Avenue•STOCKTON CA 95205-6232-(209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS 1371 r /GY02 D r CITYIMP OP/ oZ yo <br /> �1 � <br /> CROSS STREET �r0^1 fA APN0�7 - '�� ��d PARCEL SIZ.? Al PLICATION# y <br /> OWNER 6*vQ/t 6�rZ, V A- PHONao9l ,59"07 A P 10" y <br /> OWNER ADDRESS a 7i Sy�(�, viG. CITY/STATE/ZIP ,Of,, �� N <br /> CONTRACTOR CANEPA AND SONS,INC. PHONE (209)532-1136 <br /> CONTRACTOR ADDRESS 14384 CUESTA COURT clTY/STATE21P SONORA,CA 95370 <br /> C-57 WELL DR1LUNG LICENSE NUMBER 425749 EXPIRATION DATE 0731/2020 <br /> PERFORATION CONTRACTOR PHONE <br /> PERFORATION CONTRACTOR ADDRESS CITY/STATE/ZIP <br /> C-57 Well Drilling License NumberjV.2,T7501 Expiration Date <br /> Bureau of Alcohol,Tobacco and Firearms-Users of High Explosives License Number Expiration Date <br /> CHP Hazardous Material Transportation for Explosives License Number Expiration Date <br /> San Joaquin County Sheriff-Coroner Explosives Application and Permit License Number Expiration Date <br /> California Occupational Safety Health-Blaster License Number Expiration Date <br /> REASON FOR DESTRUCTION ❑ Dry Replacement Well ❑ Caved In ❑ Pit Well ❑ inactive ❑ Test Hole <br /> [)elected/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 ❑ Uncased ❑ Other <br /> Well Log copy attached ❑ Yes JS No Grout Seal ❑ No ❑ Yes_ft below ground surface(bgs) Hole Diameter inches <br /> Well Conductor Casing❑ Yes 6 No Depth of Conductor Casing ft bgs Diameter of Conductor Casing ""��""�� Inches <br /> Well Casing Diameter—inches Total Depth Wo It Depth to Water tt Depth of Casing�ft bgs <br /> DESrRucTION SPEQi KATION <br /> Sealing Material from Ha ft bgs to b ftbgs Filler Material from ft bgs to ft bgs <br /> Well casing to be perforated by one of the following methods: from ft bgs to It bgs <br /> ❑ Mills Knife Number of cuts every ft and/or S -14* <br /> E313 wi <br /> �Fo <br /> Explosives❑ Detonating cord th projectiles every ft Cl without projectile ''rr <br /> ❑ Detonating cord and boasters ❑ with projectiles every ft ❑ without projectile JO 3 <br /> ❑ Other <br /> Sealing Material Neat Cement(94 lb bag/5-6 gal water) Sand Cement S i-�t sack mix 17 gal water Bentonite Pellets �N62 Q��N �� <br /> Bentonite(20%solids urer Spec%solids_% Name Specs on File Specs Submitted 7)y FNM cciu, <br /> Placement MethodPumped Free Fall., Other OFpq�/yTq� Ty <br /> Seal Completion Comp ushroom Cap _ft bgsComplete 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 NT <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 /> PAIN( M 4 HOUR ADVANC NOTICE REQUIRED F R INSPECTIONS <br /> CONTRACTORS SIGNATURE w'' TrTLE 164 G DATE <br /> - <br /> 1 ;- <br /> aw: <br /> I I �-y 1� <br /> i�- <br /> -- I I <br /> _T_ <br /> I <br /> I ) <br /> D8P RTMENT USE ON[Y <br /> Application Accepted By Date Area <br /> Destruction Inspection SA, <br /> 41m:)Jj1 E/ Date Employee ID# <br /> COMMENTS <br /> (Nr <br /> PE SC Received Check#/ Amount Date PermlU Invoice# WellID# <br /> Codes Info B Cash emitted Service Re uest# <br /> EHD 43-08 • �/47573S— <br /> 7`7 S— WELL DESTRUCTION PERMIT <br />