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WELL DESTRUCTION PERMIT PUBUC WATER SYSTEM ❑Yes ❑No SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPT 1868 East Hazelton Avenue-STOCKTON CA 95205-6232-(209)468-3420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS/ 4(; S } cc V-T(_ CITY/ZIP `i r 1 1 CROSS STREET A P N :. ] "-C: C -1 PARCEL SIZE_LAND USE APPLICATION# OWNER <7G - ^{� I'1+�f!' L/.� PHONE ` OWNER ADDRESS v{{ 'I IV1 ,1 ] �-1� � INA CITY/STATE/ZIP L L C A CONTRACTOR i C � I '^f' . O PHONE ,�7 �) 7 /'-7 ci CONTRACTOR ADDRESS�•L 17C;/� 9• -7 CITY/STATE/ZIP A C-57 WELL DRILLING LICENSE NUMBER f< < _ EXPIRATION DATE 7- ) '�C PERFORATION CONTRACTOR M J PERFORATION CONTRACTOR ADD ESS CrTYISTATE/ZIP 9443 ❑ C-57 Well Drilling License Number xpi=Date Bureau of Alcohol,Tobacco and Firearms-Users of High Explosives License Number 3`5Expiration Date CHP Hata, Dus h"ate^a!Transportation for ExplDsives Lim Mlr,se Number o., n Da, 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 19 Inactive ❑ Test Hole ®� Detected/Suspected Well Water Contaminant(s) 7� Y Adjacent property with contamination(Address) Known Soil/Water contaminants at adjacent property 111. EXISTING WELL CONSTRUCTION DETAILS A Open Bottom ❑ Gravel Pack ❑ Uncased ❑ Other �O Well Log copy attached ❑ Yes No Grout Seal ❑ No ❑ Yes-------ft below ground surface(bgs) Hole Diameter �e'^s 5 2018 Well Conductor Casing EJ Yes No Depth of Conductor Casing It bgs Diameter of Conductor Casing - tlei/ Q Well Casing Diameter '_inches Total Depth�—ft Depth to Water ft Depth of Casing OK��r 1r Cp DESTRUCTION SPECIFICATION �r'� � M, FpgRNtq�N�' Sealing Material from 0 ftbgs to z ft bgs Filler Material _from ft bgs to ft bgs MFNP Well c�ODet one of the following methods: from ft bgs to ft bgs _ and I or cord ❑ with projectiles every ft ❑ without projectile ❑ Detonating cord and boosters ❑ With projectiles every ft ❑ without projectile ❑ Other Sealing Material eat Cement(94 lb bag/5-6 gal water) Sand Cement O'S sack mix/7 gal water Bentonite Pellets Centonite(ZU-/.solids) Manufacturer apec;Po Solids_% Name Jpecs on I-ile Specs Juomitteci Placement Method Pumped Free Fall Other I 1 Seal Completion Complete with Mushroom Cap ft bgs Complete to Existing Surface Pad 1 r 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. _ /�/ivOUR ADVANCE NOTICE ICE REOWRED FOR INSPECTIONS:, CONTRACTORS SIGNATURE / '� J OLS✓ 1 TITLE fir' �C. {�f CS•t�eAIIATE I V 5 Sp(cu�54 I � � �x-� F-X weMS • Weil s v e G r C T U 5 C hrJ 1 V h Application Accepted By `N 'T V Date v� #A Area V Destruction Inspection By {� Date r ��y, lEmp'loyee ID# COMMENTS ( L am J �zna)r-5ztg. PE SC Received Check#/ Amount Date Perm I) Involce# Well 117# Codes Into By Cash Remitted Service Request# n� 2 OO-3 EHD 43-08 /r 7+ 83Y//_/s J WELL DESTRUCTION PERMIT revised 4/14f18 Lam/ (O t0 /