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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 .. __ L �/ CALL(209)953-7697 OR INSPECTIONS EXPIRES 1 YEAR FROM DAT ISSUED JOB ADDRESS {, �F - T��L• �. %Z� CITY/ZIP ^T� - � �� t CROSS STREET 'S, N 0 /. APN �^KOC-:�-r<0C-PARCEL SIZE_LAND USE APPLI ATION# o OWNER " h L,` PHONE p H OWNER ADDRESS 4587 H✓ �'� �� 17�+ tin G.�A R�(.j3�/✓ 1 CIN/$TATE/ZIP CONTRACTOR xz"' � PHONE,4ib--3q/3 JJ �2-k' rO CONTRACTOR ADDRESS V-QV%Il` "a-7-LZ -t'Z. CIN/STATE/ZIP 1564V-p, p ,� C-57 WELL DRILLING LICENSE NUMBER 7 , EXPIRATION DATE_ PERFORATION CONTRACTOR �y'}�,��rQ•y�/1.��.�/��,( 4.��-- PHONE - %L� PERFORATION CONTRACTOR ADDRESS rra9��1-.NL+y FtiSe6� >T. CITYISTATE21PS�} -Z&r4'--J ,qS� �I C-57 Well Drilling License Number (�� Expiration Date�l•lZD / Bureau of Alcohol,Tobacco and Firearms-Users of High Explosives License Number Expiration Date CHP Hazardous Material Transportation for Explosives License Number Expiration 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 Well Inactive ❑ Test Hole Detected/Suspected Well Water Contaminant(s) Adjacent property with contamination(Address) Known Soil/Water contaminants at adjacent property EXISTING WELL CONSTRUCTION DET IL Open Bottom ❑ Gravel Pack 11Uncased ❑ Other Well Log copy attached ❑ Yes No Grout Seal ❑ No ❑ Yes ft below ground surface(bgs) Hole Diameter inches Well Conductor Casing❑ Yes X No Depth of Conduct ryCa/�sI g ft bgs Diameter of Conductor Casing inches Well Casing Diameter inches Total Depth c� th to Water k Depth of Casing ft bgs DESTRUCTION'SPECIFICATiON Sealing Material from 15trffdVt bgs to 5 ft bgs Filler Material from ft bgs to ft bgs Well casing to be perforated by one of the following methods: from ft bgs to ft bgs ❑ Mills Knife Number of cuts every ft and/or ❑ Explosives❑ Detonating cord ❑ with projectiles every ft ❑ without projectile ❑ Detonating cord and boosters ❑ with projectiles every ft ❑ without projectile ❑ Other Sealing Material Neat Cement(94 lb bag/5-6 gal water) Sand Cement sack mix/7 gal water Bentonite Pellets Bentonite(20%solid Manufacturer Spec%solids_% Name Specs on File Specs Submitted i Placement Method humped Free Fall Other Seal Completion Complete with Mushroom Cap4ft 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 REQUIRED LICENSE IS CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION LAWS. MINIMU_�?HO A VANCE NOTICE REQUIRED FOR INSPECTIONS CONTRACTORS SIGNATURE TITLE DAT12J OAYMENT - - RECEIVED PR 18 2019 -• SAN JOAQUIN COUNTY E IRONMENTAL HE,4 LTH DEPARTMENT 4t - - +.(1 _ - EP M.E T USE ON Y Application Accepted By ate Area44fA07 Destruction Inspection By � a"� D to V.4 f Employee ID# COMMENTS — N/ PE Sc Received heck# Amount Date Permit] Invoice# Well ID# Codes Info Remitted Service Reguest# 6 (q W02039522, EHD 43-08 WELL DESTRUCTION PERMIT revised 4/14/18