WP0039091 - Laserfiche WebLink

Home Browse Search

r • WELL DESTRUCTION PERMIT PUBLIC WATER SYSTEM ❑Yes ❑No SAN JOAOuiN COUNTY ENVIRONMENTAL HEALTH DEPT 1868 East Hazelton Avenue-STOCKTON CA 95206.8232-(209)468.3420 NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FRoM DATE ISSUED Joe ADoREss �f/4(� S. S}G C k o rl 5-� CrrvrLP L—c�,1 a � CROs STREE,,Tl!T CHIC ,77n APN G -�'✓U- '✓ PARCEL SQEUU^ND('USE APPLICATION 0 7 OWNER Sf`%h h P( ,CQY1( Vl /n 1Y15S �]P� PHONE�� i'I�C) OWNERADDRESs_ CITY/STATE/LP LOM II CA y 9,74 CONTRACTOR C c PHONE 3C4 -277q 11 CONTRACTOR ADOREss P C) 15 i' 4 �-y� CITYISTATEMP ((11 �.,t C A "I S 10 3 d C-57 WELL DRILLING LICENSE NUMBER cc ICj 7 EVMTION DATE - DO PERFORATION CONTRACTOR1�lo-C-'1M L Me�4 S e;J pfillOE IL :7G 1-5 PERFORATION CONTRACTOR ADDRESS I U 3CI 2 Ahd eS .4\J e CRYISTATEMP Axl Ke f-s4e'l c� F C a5.513 LI ja C-57 Well Drilling License Number Expiration Date Bureau of Alcohol,Tobacco and Firearms-Users of High Explosives License Number Expiration Date f`YO Llo.n..L.,,e I,Ae�uriM Tro.wnnrMenn Mr Cvnln�:•ea1:rnn n LL•..•Aur Cvni.nl:nn flea m uNvuauv„,ui�ny,�a.w uw„ac,.w„w, �.•yuuw„✓o.c � 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 W Inactive ❑ Test Hole Detected/Suspected Well Water Contaminant(s) Adjacent property with contamination(Address) Known Soil/Water contaminants at adjacent property ExIs-nNO WELLCONSTRUCTIoN DETAILS Open Bottom ❑ Gravel Pack 13Uncased ❑ Other Well Log copy attached ❑ Yes �. No Grout Seal 11 No ,!S[\Yes Z'ft below ground surface(bgs) Hole Diameter inches Weft Conductor Casing❑ Yes No Depth of Conductor Easing ft bgs Diameter of Conductor Casing inches Well Casing Diameter__J(v inches Total Depth L4f\ � ft Lft Depth to Water 0 Depth of Casing� It bgs DESTRUCTION SPECIFICA I / Sealing Material from ft bgs to_1 ft bgs Filler Materiel from R bgs to It bgs Well casing to be perforated by one of the following methods: from ft bgs to It bgs ❑ Mills Knife Number of cuts every ft and/or i Explosives❑ Detonating cord ❑ with projectiles every It ❑ without projectile �, vc vnal:nn n.•nl nnA Annnlnrr n •,.M n.nin�:len n•.nn. a 1"1 �.'uA�..1 'nnNin ❑ Othar Sealing Material Neat Cement(94 lb bag/5-6 gal water) x Sand Cement 105 sack mix/7 gal water Bentonite Pellets I Bentonite(20%solids) Manufacturer Spec cr solids he Name Specs on fiie Specs Submitted Placement Method Pumped Free Fall Other Seal Completion Complete with Mushroom Cap 5 it bgs Complete to Existing Surface Pad i 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. MINIMUM 4d HOUR ADVANCE NOME E teKttU1KCU CONTRACTORSSGNATURE G W rVi<IIVS�YtI,11VNJv 1G TITLE 1 �\. DATE V) ❑,,�.;z S 1(,•(% ti � ut1�o a Wt 11 T. s"qi,Joq 6 ?018 h�FN��R) i co" EM TMENT USE ON FgR�Tq�ry Application Accepted By AiffZLI&I Date Area MFiyT Destruction Inspection By l Date11,17 P Employee IDS COMMENTS PE SC Received Check#/ Amount Permit/ Codes info B Cash mitted Date Service Request# Invoice# WeiIID# V� � EHO 43-08 WELL DESTRUCTION PERMIT