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WELL DESTRUCTION PERMIT <br /> PUBLIC WATER SYSTEM [:]Yes)No <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 /> Joe ADDRESS I ID 4 ffA WL <br /> CITYILP t J <br /> CROSS STREET A 14 1 ✓'0-0S PARCEL Siz LAND USE APPLICATION# 9 <br /> �(�f <br /> OWNER 1XIn T71ArJJkJD t� � PHONE � <br /> OWNER ADDRESS 6H-7X��Foc b c l al N GL o CITY/STATE/LP Gsk t) Ppk Ynr'a yl 0W <br /> CONTRACTOR C o1Si t-e Y�"C��( DiY I L(1 h PHONE It • "t IOft• �Z / <br /> CONTRACTOR ADDRESS PJ I�coc I Lf '6 '] CITY/STATEMP R W�"bct n IC. 9,f`3 U-7 <br /> C-57 WELL DRILLING LICENSE NUMBER U—1 L��J EXPIRATON DATE <br /> PERFORATION CONTRACTOR PHONE <br /> PERFORATION CONTRACTOR ADDRESS CITY/STATEZP 11 <br /> C-57 Well Drilling License Number ( r.7 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 /> Detected/Suspected Well Water Contaminanqs) <br /> Adjacent property with contamination(Address) <br /> Known Soil/Water contaminants at adjacent property <br /> EXISTING WELL CONSTRUCTION DETAILS ❑ Open Bottom ❑ Gravel Pack ❑ Unoased ❑ Other <br /> Well Log copy attached ❑ Yes hill No Grout Seal ❑ No ❑ Yes It below ground surface(bgs) Hole Diameter inches <br /> Well Conductor Casing a Yes ❑ No Depth of Condu for Casing It bgs Diameter of Conductor Casing inches <br /> Well Casing Diameter_u_inches Total Depth �� It Depth to Water ft Depth of Casing it bgs <br /> DESTRUCTION SPECIFICATION <br /> Sealing Material from _ ft bgs to_ ft bgs Filler Material from_ ft bgs to ft bgs <br /> Well casing to be perforated by one of the following methods: from it bgs to it bgs <br /> ❑ Mills Knife Number of cuts every ft and/or <br /> ❑ Explosives❑ Detonating cord ❑ with projectiles every ft ❑ without projectile <br /> ❑ Detonating cord and boosters ❑ with projectiles every ft ❑ without projectile <br /> ❑ Other <br /> Sea' Cement(94 Ib bag/5-6 gal water) Sand Cement sack mix/7 gal water Bentonite Pellets <br /> tonite(20%solids) Manufacturer Spec%solids_% Name Specs on File Specs Submitted <br /> Placement Met o Pumped Free Fall Other <br /> Seal Completion Complete with Mushroom Cap ft 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. 1 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 /> IN 48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br /> CONTRACTORS SIGNATURE TITLE <br /> - I ' <br /> R c�FNT <br /> T <br /> DEC <br /> -- -i-i­r­- --- -- ?0 <br /> JOA <br /> 18 <br /> T e <br /> l/E'gCTy, D0 MFNTq�N7 " <br /> ARTMENT <br /> D ^T ENT USE ONLY/Application <br /> Y/ <br /> Application Accepted By Date / V Area <br /> Destruction Inspection By " Date Employee ID# <br /> COMMENTS <br /> PE SC Received hec Amount Date PermlU Invoice# Well ID# <br /> ode Ifo B Cash R itt d Se ice Re uest# <br /> 1011111-0 <br /> EHD 43-08 WELL DESTRUCTION PERMIT <br /> revised 4/14/18 <br />