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WELL DESTRUCTION PERMIT PUBLIC WATER SYSTENi❑Yes ❑No SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPT 1888 East Hazelton Avenue-STOCKTON CA 95205-11232-(209)488-3420 NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED tyy ,1 K JOB ADDRESS IV O y J• V+�t C%'ti r,'tiv CITYIZIP CROSSSTREEr 01'1 AAL/�'ti+il SI` }� t APN 1�y-Z�U 12 G7 PARCEL 512EY-v ND USE APPLICATION# tl OWNER }Ver / Al-srwiL. �•SLo.e•JJy?1,7 PHONE 1 ,{ OWNERADDRESS l��3 s' ti1'n)«.'T jCP!'• CITY/STAWJZW AA/ ^� c,". ICI'+ `�'S•3'S 1 CONTRACTOR '� l�t�1/rfw. PHONE �1 LS - 3 i 3 - 3 E'�"4 @ _ CONTRACTOR ADDRESS 4�� do't'2. Re,a CITY/STATE/ZIP /A�'�r�'�^C s 4 A C57 WELL DRILLINO LICENSE NUMBER "IS��3 _ EXPIRATION DATE J l�ZG7'CL` PERFORATION CONTRACTOR PHONE PERFORATION CONTRACTOR ADDRESS CITY/STATE/7JP ❑ 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 Dale California Occupational Safely Health-Blaster License Number Expiration Data REASON Fog DEsTRucmN ❑ Dry ❑ Replacement Well ❑ Caved In ❑ Pit Well Of inactive ❑ Test Hole Detected/Suspected Well Water Contaminant a) 11"4 t VL^C Adjacent property Wtb contamination(Address) it? Sr i, P-i` Known Soil/Water contaminants at adjacent property M G t t/OL EXISTING WELL CONSTRUCTION DETAILS Cl Open Bottom ❑ Gravel Pack ❑ Uncased .N- Other�^Ya•"✓F�'� Well Log copy attached ❑ Yes J9 No Grout Sea] ❑ No ❑ Yes It below ground surface(bgs) Hole Diameter Inches Well Conductor Casing❑ Yes jif No Depth of Conductor Casing ft bgs Diameter of Conductor Casing inches Well Casing Diameter_* __inches Total Depth V, R Depth to Water 24 R Depth of Casrng 0,k-,0 t, ftbgs DESTRUCTION SPECIFICATION Sealing Material from I(V—it bgs to 0 ft bgs filler Material from ft bgs to R bgs Well casing to be perforated by one ofthe following methods: from It bgs to ft boS ❑ Mills Knife Number of arts every it and/or ❑ Explosives❑ Detonating cord ❑ with projectiles every__ft ❑ without projectile /lf ❑ De n U cord and boosters ❑ with projectiles query T;ft ❑ without projecble l)t116r-,�t[f� L �l +.) K+w�" 9111 I to ,4 , r.•/� t n Sealing Material eat Cemein-!P4 1b bag/5-8 gaf water) Send Cement sackln&/7 gal water Bentonite Pellets A�4 Benton ite(20%sof s 1Glanufacturer Spee%solldS_% Name Specs on File Specs Submitted Placement Method Pumped Free Fall Other �. Seal Completion Complete with Mushroom Cap ft bgs Complete Existing Surface a I HEREBY CERTIFY THAT I HAVE PREPARED TIS /' VVITH SAN ORK LL NE CORDANCE JOAQUIN COUNTY ORDINANCES,STATE LAWSHAND RUL STAND REGULATIONS.AND THAT THEION NI ALSO(CERT FY OTHAT MYC EQUIRED LICENSE IS CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITi /, WORKERS COMPENSATION LAWS. t.�-��II Q. <'�1D MINI U HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS p� "�C ROh�CDU !3 CONTRACTORS SIGNATURE �+ - TnLE P-';Z.J M"�-'iCd-DATE 0 �6� l D �Fpgr�TM�4 �' . ------------------ ----— I----- - ... .1�-..apt.�. .. ---'----'L - ►----.-----..._.._. -- ' -- NT CEIVED _I..__._______ ---'- 4 f:.:.• �� _— j 11.....1..-J._ UG 13 2018 -I._XV.....-..: :-_ass.s�i__ ; I:j&.:?I ...+.....1: ......... .ONMENT AL HEALTH ERTMENT USE ONVY Application Accepted By Date Area ��G/►rl/(�C/� Destruction Inspection By 'C+/✓7 Data 2 Employee[DO' COMMENTS 11 L PE SC Received Check#! Amount Date Permitl invoice# well ID# Codes Info emitted Service Re uest# EHD 43-08 WELL DESTRUCTION PERMIT revised 4/14118