WP0038859 - Laserfiche WebLink

Home Browse Search

WELL DESTRUCTION PERMIT PUBLIC WATER SYSTEM ❑Yes ❑No SAN JOAOUIN COUNTY EW4MONNENrAL HEALTH DEPT 1868 East Hazelton Avenue-STOCKTON CA 95205-6232-(209)468-3420 NON-REFUNDABLE PERMIT C i EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS 4:74L) J. ��L'��-rGn �C� /^ (� CITYRIP L-0 cl r Ci5�9J CROSS STREET 1'I C.f n C`I Lfl APN C PARCEL SIZE_LAND UaE APPLICATION c OWNER t/ t C.IN t� i L;`.- AL,LC PHONE 5 c 'T --7 z OWNER ADDRE33 r rw O I A t`1 S Q V t 1,-+'c AA CITY/STATE/LP�L'�i .V-7'75 ( A C1 J:!1:2 CONTRACTOR / Sc 1 1^6 PHONE S/C, CONTRACTOR ADDRESS LJ fSX 4��J•t 7( CITYISTATE/ZIP C'�1 T 4 C C-57 WELL DRILLING LM&M NUMBER y L4 Sill (�T f FxPtRAnoN DATE .] U PERFORATION CONTRACTORTI I(1P Mc ��t:+lY1 V `''�t V'!r PHONE (' p ( at PERFORATION CONTRACTOR AD"I.1a3C^[ YWC� ' L ` CITYISTATEMP LIle r] tF((.1 iCACA 4310 `C� C-57 Well Drilling License Number Fxpiralion Date Bureau of Alcohol,Tobacco and Firearms-Jsers of High Explosives License Number Expiration Date CHP Hazardous Vale,-&.T.ans;,r,:.a:on.G E)V.Ca:€s L cen se Number Expirallon 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 Wel'! ❑ Inactive ❑ Test Hole Delacied;Suspected Well Water COntaminangs) Adjacent property win contamination(Address) Known Soil)Water Contaminants at adjacent property ExISTINO WELL CONSTRUOTION DETAILa ❑ Open Bottom ❑ Gravel Pack ❑ Uncased E3Ciher Well Loa cow atlstlled O Yes 1IL No Grout Seal ❑ No 11 Yes 1 below Grdmd surface(bps) Hole Diameter inches Wall Conductor Casing La Yes X No depth or Oonductor Casing R bgs Diameter of Conductor Casing _I Well Casing Dlameter �(',?—inches Total Depth -2(,10 R DOM to Water _ft Depth of Casing DesTaaci ton Srmilfit A[ION Sealing Material from ft bgs to ft logs Filler Material _from R bgs to R bgs Well casing to be perforated by one of the following methods: __ .__ from R Cgs to n DpE U Mills Knife Number of cuts every R and!or Explosives❑ Detonating cord ❑ With projectiles every ft ❑ without projectile ❑ OVW Sealing Material Neat Cement(94 lb bag 15-6 gal water) Sand Cement sack mix/7 gal water Bentonits Pellets Bentonite(20%solids) Manufacturer Spec%solids_% Name Specs on File Specs Submitted Placement Method Pumped Free Fall Other Seal Completion Complete with Mushroom Cap 3_ft 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 REWIRED LICENSE IS CUKKtNI ANU AI:IIVt WITH IHt CALIFUKNIA LUN IKACIUKS ;TA–it: LICENSE tlUAHU AND IMAI 1 AM IN I:UMYLIANCt WITH ALL WORKERS COMPENSATION LAWS. �/7J�W,� CONTRACTORS SIGNATURE W{.y-•-/! / / Kl TIT.�; c e p�S ,c�l'n TE C, ) I N CC-- 3 J I 4— -7- DEPARTMENT DEPARTMENT USE ONLY Application Accepted By Date Area Destnlction Inspection By -__ Date Employee IDS COMMENTS PE SC Rtteelved CheckW Amount Date Pern" Invoice Well IDR Codes Info 8 Cash Remitted Servlce Request M EMD 4308 WELL DESTRUCTION PERMIT I -,..—a,.♦11