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WELL DESTRUCTION PERMIT �✓ PUBLIC WATER SYSTEM ❑Yes ❑No SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 East Hazelton Avenue-STOCKTON CA 95205 - (209)468-3420 .,NON-REFUNDABLE PERMIT CA 209 -7 7 FOR INSPECTIONS / EXPIRE§ 1 YEAR FROM DATE JSSUED JOB ADDRESS � 4j CITYIZIP </,v� �(/ m a CROSS STREET APN Ok PARCEL SIZE LAND USE APPLICATION# x OWNER /' PHONE mi rn OWNER ADDRESS = ✓ CITY/STATE/ZIP CONTRACTOR PHONE CONTRACTOR ADDRESS / CITY/STATE/ZIPY _L }—✓\ C-57 WELL DRILLING LICENSE NUMBER CJ s�U EXPIRATION DATE PERFORATION CONTRACTOR PHONE PERFORATION CONTRACTOR ADDRESS CITY/STATE/ZIP r ❑ 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 X 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 X No Grout Seal No El Yes It 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 inches Total Depth It Depth to Water_ ft Depth of Casing __ft bgs DESTRUCTION SPECIFICATION f Sealing Material from _-3 ft bgs to It bgs Filler Material i 0 from Z ft bgs to t bgs Well casing to be perforated by one of the following methods: from ft bgs to ft bgs ❑ Mills Knife Number of cuts every It and/or ❑ Explosives ❑ Detonating cord ❑ with projectiles every It ❑ without projectile ❑ Detonating cord and boosters ❑ with projectiles every ft ❑ without projectile ❑ Other Sealing Material Neat Cement(94 Ib bag/5-6 gal water) Sand Cement �� > sack mix17 gal water Bentonite Pellets Bentonite(20%solids) Manufacturer Spec%solids % Name Specs on File Specs Submitted Placement Method Pumped --" Free Fall Other Seal Completion>LComplete with Mushroom Clap 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. /MINIMU 4 HOUR V CE NOTICE REQUIRED FOR INSPECTIONS — � E' / n CONTRACTORS SIGNATURE TITLE /1, �l_ ) DATE ) .. ! PAYMENT . .. RECEIVED APR 17 2018 _...._ gAN JOAnUIN COUNTY f___ _ .. f_ E ENVIRONMENTAL lC HEALTH DEPARTMENT r' ...f...w. ..f, (jtt ti _.,,...... .� ...y-.._. t ..._.A.._ r ..� �- _ .. _ _. 111 I P T M E N T USE O N Y n Application Accepted By ` Date_ Area Destruction Inspection By __ Date Employee ID# COMMENTS r PE SC Received I'ChAeW Amount Date PermiU Invoice# Well ID# Codes Info B ash Remitted Service Request# ob3fsl EHD 43-08 WELL DESTRUCTION PERMIT 4/30/12