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WELL DESTRUCTION PERMIT <br /> PUBLIC WATER SYSTEM ❑YeS 0 <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 East Hazelton Avenue-STOCKTON CA 95205 - (209))468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS / CITY/ZIP <br /> CROSS STREET h� APN " PARCEL S43 LAND USE APPLICATION# <br /> i <br /> - <br /> OWNER j PHONE 131- 3 <br /> ��t� <br /> CJS n <br /> OWNER ADDRESS c�I, /yv/� CITY/STATE/ZIP <br /> CONTRACTOR /v/ /V r PHONE <br /> CONTRACTOR ADDRESS CITY/STATE/ZIP <br /> ❑ C-57 WELL DRILLING LICENSE NUMBER `f�(r( /� EXPIRATION DATE <br /> PERFORATION CONTRACTOR PHONE <br /> PERFORATION CONTRACTOR ADDRESS CITY/STATE/ZIP <br /> ❑ C-57 Well Drilling License Wymber 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 Contaminant(s) _ <br /> Adjacent property with contamination(Address) <br /> Known Soil/Water contaminants at adjacent property <br /> EXISTING WELL CONSTRUCTION DETAILS W Open Bottom ❑ Gravel Pack ❑ Uncased ❑ Other <br /> Well Log copy attached ❑ Yes ❑ No Grout Seal ❑ No ❑ Yes -_____It below ground surface(bgs) Hole Diameter inches <br /> Well Conductor Casing ❑ Yes ❑ No Depth of Conductor Casing ft bgs Diameter of Conductor Casing inches <br /> Well Casing Diameter___ N inches Total Depth /400, -ft Depth to Water___ It Depth of Casing - It bgs <br /> DESTRUCTION SPECIFICATION <br /> Sealing Material from It bgs to ___ It bgs Filler Material_ _____ ____from ft bgs to ft bgs <br /> Well casing to be perforated by one of the following methods: --from ft bgs toIt bgs <br /> ❑ Mills Knife Number of cuts every ft and/or <br /> ❑ Explosives ❑ Detonating cord El with projectiles every . ft ❑ without projectile L "JE <br /> ❑ Detonating cord and boosters ❑ with projectiles every _It ❑ without projectile <br /> ❑ Other_ <br /> Sealing Material Neat Cement(94 lb bag/5-6 gal water) Sand Cement sack mix/1 gal water /VBentonite Pellets <br /> Bentonite(20%solids) Manufacturer Spec%solids --% Name _ _ Specs on File Specs Submitted <br /> Placement Method Pumped � Free Fall Other <br /> Seal Completion Complete with Mushroom Cap It 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. I 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 /> U 24 ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br /> CONTRACTORS SIGNATURE 1L/ _TITLE DATE <br /> ID PARTMENT USE ONL <br /> Application Accepted By J Date Area _ <br /> Destruction Inspection By !(fQG'l�� J ________ Date�� Z�'�� Employee ID# _ <br /> COMMENTS l��L � / II`�u ��1���`�' vJc� i Qrd r� <br /> - PAYmsNT <br /> RCncnir.) <br /> PE SC Received Fh!cW Amount Date Permit/ Invoice# <br /> Codes Info _ ash Remi ted Service Request# <br /> 19P73 A- we00SAN J AQUIN COUNTY <br /> HEALT i DEPARTMENT <br /> EHD 43-08 WELL DESTRUCTION PERMI r <br /> 4/30/12 <br />