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0- <br /> • WELL DESTRUCTION PERMIT Z <br /> SYSFEM❑Yes u <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE 3"°FL-STOCKTON CA 95202-(209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> 'S Q Q N <br /> Joe ADDRESS CrrY/ZIPy f, �., <br /> CROSS STREET t1 i Nf. PN I I I O PARCEL SIZE LO USE APPLICATION# <br /> OWNER �� T(u LHONE <br /> OWNER ADDRESS 2-1 `�, ��l t�N�/� CITY/STAT�EMIP <br /> CONTRACTOR �� �-2 / Clf <br /> � •' v— `,,1f'/ � �\ L PHONE T�+ •� 1`}-P,� ' T <br /> CONTRACTOR ADDRESS J C.(J J W "I�-"w �' CrEY/STATE/LIP �� ` ` <br /> C-57 WELL DRILLING LICENSE NUMBER - EXPIRATION DATE O <br /> PERFORATION CONTRACTOR PHONE _ <br /> PERFORATION CONTRACTOR ADDRESS CITY/STATE/Z1P <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 DESTRU ❑ Dry 11ReP ReplacementWell ❑ Caved In El Pit Well Inactive [ITest Hole <br /> CTION <br /> Detected/Suspected Well Water Contamimut(s) V 0 G <br /> Adjacent property with contamination(Address) f� <br /> Known Soil/Water contaminants at adjacent property A� <br /> EXISTING WELL CDNSTltumoN DETAILS ❑ Open Bottom ❑ Gravel Pack ❑ Unca.Sed ❑ Other <br /> Well Log copy attached ❑ Yes ❑ No Groat Seal ❑ No ❑ Yes ft 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_ inches Total Depth fo`•qO ft Depth to Water ft Depth of Casing ft bgs <br /> DESMUCTION SPECIFICATION tt�� n <br /> Sealing Material from t✓ ft bgs to 90 ft bgs Filler Material from ft bgs to ft bgs <br /> wen casing to be perforated by one of the following methods: from ft bgs to ft bgs <br /> ❑ Mills Knife Number of cuts every ft and/or <br /> ❑ Explosives ❑ Detonating cord ❑ with projectiles everyft ❑ without projectile <br /> ❑ Detonating cord and boosters ❑ with projectiles every ft ❑ without projectile <br /> ❑ Other <br /> Sealing Material nt(94 Ib bag/5-6 gal water) )k Sand Cement sack mix 1 7 gal water ❑ Bentonite Pellets <br /> ❑ Brntonite(2001/6 iotids) ❑ Manufacturer Spec%solids—% Name ❑ Specs on File 13 Specs Submitted <br /> Placement Method)K,Pumped ❑ Free Fall ❑ Other <br /> Seal Completion ❑ Complete with Mushroom Cap ft bgs [3 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 AC-ITVE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSA LAW <br /> MIN M 24 HOUR ADVANCI N I E REQUIRED FO/R INSPECTIONS <br /> V' DATE <br /> CONTRACTORS SIGNATURE TITLE <br /> vl �" <br /> DEPARTMENT USE ONL PA/Y-�MENT <br /> Application Accepted By j1, - �/� Date - 4/���REVEIVED <br /> Destruction Inspection By�S►J)C�n tZ� Date S Employee ID# <br /> COMMENTS JUL 1 3 2005 <br /> AN JOAQUIN COUNT <br /> EN�)RONMENTAL <br /> '� PE SC Received Check#/ AmountPermit/ Invoice# Welles EALTH DEPANTMEN <br /> Codes Info <br /> RemittedService R nest# <br /> a 5�- <br /> 3" <br /> 0 38 <br /> Well Deswceon Pmnit <br /> EHD 43-02-008 <br /> 1/27/2005 <br />