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WELL DESTRUCTION PERMIT PUBLIC WATER SYSTEM ❑Yes ❑No SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPT 1868 East Hazelton Avenue-STOCKTON CA 95205.6232-(209)468-3420 NON-REFUNDABLE $PERMIT J CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEARa�FROM DATE ISSUED JOB ADDRESS /A✓� N• t.l�Crt/Sl' T`/QEE CITY/ZIP CROSSSTREET 1—'e TTLL- �'!�� APN — D PARCEL/SIZE�Vy�L'ALND(USE APPLICATION# 0 OWNER �/t� /yl�TTLE PHONE`/A�,� OWNER ADDRESS / #V r CITY/STATE/ZIP CONTRACTOR IA I/ PHONE W 'a 1.. 0�3 CONTRACTOR ADDRESS Cl�G TIA -f T CITY/STATE/ZIP SOA/pj", CA - 95'37® C-57 WELL DRILLING LICENSE NUMBER_ /I+. EXPIRATION DATE 7/s0J,0 PERFORATION CONTRACTOR PHONE PERFORATION CONTRACTOR ADDRESS CITY/STATE/ZIP C-57 Well Drilling License Number s7N Expiration Date 11*/20 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 Caiifomia Occupational Safety Health-Blaster License Number Expiration Date REASON FOR DESTRUCTION ❑ Dry Replacement Well ❑ Caved In ❑ Pit Well ❑ Inactive [3Test Hole Detected/Suspected Well Water Contaminan(s) Adjacent property with contamination(Address) Known Soil/Water contaminants at adjacent property EXISTING WELL CONSTRUCTION DETAILS ❑ Open Bottom ❑ Gravel Pack Cl Uncased ❑ Other Well Log copy attached ❑ Yes A No Grout Seal ❑ No ❑ Yes it below ground surface(bgs) Hole Diameter_ inches Well Conductor Casing Yes ❑ No Depth of Conductor Casing L AV— ft bgs Diameter of Conductor Casing_ inches Well Casing Diameter inches Total Depth_110 ft Depth to Water If Depth of Casing ft bgs DESTRUCTION SPECIFICATION Sealing Material from Z�jy ft bgs to_0 it bgs Filler Material from it bgs to ft bgs Well Casing to be perforated by one of the following methods: from it bgs to it bgs ❑ Mills Knife Number of cuts every ft and/or ❑ Explosives❑ Detonating cord ❑ with projectiles every It ❑ without projectile ❑ Detonating cord and boosters ❑ with projectiles every it ❑ without projectile ❑ Other Sealing Material Neat Cement(94 lb bag/5-6 gal water) Sand Cement p• sack mix/7 gal water Bentonite Pellets Bentonite(20%solids) Manufacturer Spec%solids_% Name Specs on File Specs Submitted Placement Method umped Free Fc Other Seal Completion Complete wI Mushroom Cap_ r It 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. MIN Ivl48 H UR ADVANCE NOTICE REQUIRED FOR INSPECTIONS CONTRACTORS SIGNATURE TITLE DATE / /T ot Alto a- a �D - a ..-_A _ j --- - -� : I .. I D R T M E N T USE O L Y Application Accepted By Date L7 NO Area Destruction Inspection By Date c Employee ID COMMENTS pu PE SC Received Check#/ Amount Permit/ Date Codes Info B ash emitted S ice Request# Invoice# Well ID# EHD 43-08 WELL DESTRUCTION PERMIT b revised 4/14118 ��",Y (((Y�� •