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WELL DESTRUCTION PERMIT <br /> PUBLIC WATER SYSTEM ❑Yes ❑No <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 c` I �da IV< <M s 2� CITY21P 7_'L Q O <br /> rn <br /> CROSS STREET - _` APNI-W 07 I'>-I'>- PARCEL SIZED/-�OLAND USE APPLICATION# <br /> OWNERw <br /> _ i_`lctt +�� k �' rM�' PHONE(5]0 T3 <br /> OWNER ADDRESSS-1 q0 ]�C L-A CITY/STATE/ZIPL r4 CA <br /> CONTRACTOR A V ti f A ry t 1 L h./ <br /> IM —yf. PHONE <br /> CONTRACTOR ADDRESS_ act A i6ees kJ! CITY/STATE/ZIP /My e-f4o Ca <br /> C-57 WELL DRILLING LICENSE NUMBER b_6fJQ?,7, EXPIRATION DATE (4-?U- <br /> PERFORATION CONTRACTOR PHONE <br /> PERFORATION CONTRACTOR ADDRESS CITY/STATE/ZIP <br /> ❑ C-57 Well Drilling License Number 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 Open Bottom ❑ Gravel Pack ❑ Uncased ❑ Other <br /> Well Log copy attached ❑ Yes No Grout Seal ❑ No ❑ Yes _ft below ground surface(bgs) Hole Diameter inches <br /> Well Conductor Casing ❑ Yes No Depth of Conduc or Casing Diameter of Conductor Casing inches <br /> Well Casing Diameterinches Total Depth'---ft Depth to Water_ It Depth of Casing It bgs <br /> DESTRUCTION SPECIFICATION <br /> Sealing Material from 5___ft bgs to __.d ft bgs Filler Material _ from ft bgs to ft bgs <br /> Well casing to be perforated by one of the following methods: from ft bgs to ft bgs <br /> ❑ Mills Knife Number of cuts every It and/or <br /> ❑ Explosives ❑ Detonating cord ❑ with projectiles every ft ❑ without projectile <br /> ❑ Detonating cord and boosters ❑ with projectiles every ft ❑ without projectile <br /> ❑ Other <br /> Sealing Material Neat Cement(94 lb bag/5-6 gal water)-1 Sand Cement sack mix/7 gal water Bentonite Pellets <br /> Bentonite(20%solids) � Manufacturer Spec%solids % Name Specs on File Specs Submitted <br /> Place ent Method Pumped 1 Free Fall / Other <br /> Seal Completion)( Complete with Mushroom Cap_ 2�- ft 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 /> 70 <br /> MI_I IMUM HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br /> CONTRACTORS SIGNATURE TITLE DATE <br /> ... ... ...... ...._. ._............ <br /> S <br /> ... <br /> �... . <br /> ELIE <br /> 'QC&A r <br /> I y0 I <br /> . _._.� F119 <br /> �Nh' <br /> R Tq <br /> ��Z�EfPRTIMENT USEONL lIf <br /> Application Accepted By Date Area "C <br /> IV <br /> Destruction Inspection By Date Employee IDD# <br /> COMMENTS O Id Q CJI <br /> t <br /> PE SC Received heckW) Amount Permit/ <br /> Codes Info B as Remitte Date Service Request# Invoice# Well ID# <br /> WPM 'S <br /> � I <br /> EHD 43-08 WELL DESTRUCTION PERMIT <br /> 4130/12 Ob 0 v 'e Y- a-'4 yn'Q a J <br />