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WELL DESTRUCTION PERMIT ` PUBLIC WATER SYSTEM ❑Yes o SAN JOAOUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 East Hazelton Avenue-STOCKTON CA 95205 - (209)468-3420 NON-REFUNDABLE PERMIT CALL 209 953-7�697�FOR INSPECTIONS EXPIRES 1 YEAR FROM DATF ISSUED JOB ADDRESS r c ?S✓ CITY/ZIP l� m ` A Y CROSS STREET APN L ,- 3 f 0 71 ?-2 PARCEL SIZ NND�UUSE APPLICATION# Al OWNER PHONE -/ / 7 r: OWNER ADDRESS CITY/STATE/ZIP /` � CONTRACTOR �� 1 _ PHONE !:Z CONTRACTOR ADDRESS CITY/STATE/ZIP C-57 WELL DRILLING LICENSE NUMBER EXPIRATION DATE PERFORATION CONTRACTOR PHONE PERFORATION CONTRACTOR ADDRESS CITY/STATE/ZIP ❑ 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 ❑ 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 W Open Bottom ❑ Gravel Pack ❑ Uncased ❑ Other Well Log copy attached ❑ Yes ❑ No Grout Seal ❑ No ❑ Yes_ It below ground surface(bgs) Hole Diameter inches Well Conductor Casing ❑ Yes If ❑ No Depth of Conductor Casing ft bgs Diameter of Conductor Casing inches Well Casing Diameter 6—inches Total Depth ___X5 It Depth to Water 54.It Depth of Casing _ ft bgs DESTRUCTION SPECIFICATION Sealing Material from ft bgs to ___ It bgs Filler Material_ from It bgs to ft bgs Well casing to be perforated by one of the following methods: __._from ft bgs toft 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 lb bag/5-6 gal water) Sand Cement Sack mixll gal water "If Bentonite Pellets _ Bentonite(20%solids) Manufacturer Spec%solids_ _so Name Specs on File/ Specs Submitted Placement Method Pumped Free Fall Other Seal Completion Complete with Mushroom Cap ft bgs Complete to Existing Surface Pad 73�C j 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 I ONCE NOTICE REQUIRED FOR INSPECTIONS CONTRACTORS SIGNATURE TITLE �� DATE ! t �. ,. .._ ........... .� PAYMENT RECEIVED 20.19 ,e_:r �j /!V SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT DE ARTM ENT USE ONYY Application Accepted By _ _ Date Area _y __ _q_____ _ �/n� __. --- Destruction Inspection By Date V _____ Employee ID#___ __._ AK, —4_ COMMENTS PE SC Received Chec Amount Permit/Date Invoice# Well ID# Codes Info By Cash Remitted Service Request ft _ 157q OR' EHD 43-08 WELL DESTRUCTION PERMIT 4/30/12