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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 "ALL(209)953-7697 FOR INSPECTIONS EXPIRES'I YEAR FROM DATE ISSUED � JOB ADDRESS c' CROSS STREET ��f��V1VS I1�IL APN �— PARCEL$IZE��AND USEAPPucAnoN # �O OWNER 1 t Sv� �'�� _ PHONE '1 {.. �4 � cmisrATEruP OWNER ADDRESS C, .�' �`•�` "f'nt C, CONTRACTOR �O S��C✓^ ..i ` , �� PHONE r Z�`I - r"i?, �� C j a '( CrIY/STATEILP CONTRACTOR ADDRESS 7—C C�w'•' 1 P1vC_ �� C-57 WELL DRILLING LICENSE NUMBER (k ()Z C11 F) EXPIRATION DATE 2" -� PHONE PERFORATION CONTRACTOR PERFORATION CONTRACTOR ADDRESS CrrY/STATE ZIP License Number Expiration Date ❑ C-57 Well Drilling Expiration Date Bureau of Alcohol,Tobacco and Firearms-Users of High Explosives License Number P' License Number Expiration Date CHP Hazardous Material Transportation for Explosives Ex iration Date _ San Joaquin County Sheriff-Coroner Explosives Application and Permit License Number P License Number _ Expiration Date California Occupational Safety Health-Blaster Inactive ❑ Test Hole nv REASON FOR DESTRUCTION Dry ❑ Replacement Well ❑ Caved In ❑ Pit Well ❑ Detected i Suspected Well Water Contaminant(s) Adjacent property with contamination(Address) i Known Soil/Water contaminants at adjacent property__ i ------------ ❑ Uncased ❑ Other i� A EXISTING WELL CONSTRUCTION DETAILS PC Open Bottom ❑ Gravel Pack Inches Well Log copy attached ❑ Yes ❑ No Grout Seal ❑ No ❑ Yes__-,_ft below ground surface(bgs) Hole Diameter rC Well Conductor Casing❑ Yes ❑ No Depth of Conductor Casing It bgs Diameter of Conductor Casing inches 0 inches Total Depth uC' k Depth to Water 7 fJ ft Depth of Casing t�1 t Well Casing Diameter t Dr.SFRL(7ION SPECIFIC AWL �L^;� from it bgs to ft bgs 18 (� 0 Sealing Material from O fl bgs to E'U ft bgs Filler Material 6t2 .—- Well casing to be perforated by one of the TollowlnQ methods: n�• from 9 bgs to ft bgs ❑ Mills Knife Number of cuts every -ft and/or ❑ with projectiles every ft ❑ without projectile ❑ Explosives❑ Detonating cord ft without projectile it ❑ Detonating cord and boosters ❑ with projectiles every ❑ �- ❑ O11ter---- -�- - sack mix/7 gal water Bentonite Pellets e- Sealing Material_ e t Cement(941b bag 15-6 gal water) Sand Cement Specs on File Specs Submitted ntonite(20%soli s ufacturer Spec%solids_% Name e Placement Method Free Fall 1 / Other ft �r7 bgs Complete to Existing Surface Pad h^ Seal Completion Complete with Mushroom Cap S S I HEREBY CERTIFY THAT 1 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 C CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL �' v WORKERS COMPENSATION LAWS. MINIMUM 48 HOUR ADVANCE NOTICE REQUIRED FOR iNSPECTiQ-46 rfyi � -1 TITLE ! DATE \ CONTRACTORS SIGNATURE x l JS-q4 �'Ro�,/1vC I !c,�� y�FpgRFT DQNry d I �2� MFNT Ca Sh- P t1R MENT USE ONLY _� Date Area Application Accepted By Dale Employee I N Destruction Inspection By COMMENTS Amount Permit/ Invoice# Well ID# PE SC Received Check#! Date Service Request# Codes Into ash emitted -�. -Y• V� ^ " V WELL DESTRUCTION PERMIT EHD 41-08 G revised 4114118