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WELL DESTRUCTION PERMITrVBLW EK OY5 I UNI LJ Yes a..r+ No SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE 3R0 FL-STOCKTON CA 95202-(209) nnn NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DAT JOB ADDRESS I � CITY/Lm m t!D.011.fr APN dJ I �(� Zo PARCELSIZE- CROSS STREE�tT LAND USE APPLICATION# OWNER A PHONE1a�r) N 1 X005 OWNER ADDRESS CITWSTATE/Z. CONTRACTOR PRUNE Q' ,5 I-.?.'t z/ VENT HEALTH CONTRACTOR ADDRESS CITY/STATE/ZIP Al r L/! �7 / "tet R/SERVICES ❑ C-57 WELL DRILLDVGLICENSE NUMBER EXPIRATION DATE PERFORATION CONTRACTOR w D Weo /& -1 16/� PHONE — qr,� 14/�+s PERFORATION CONTRACTOR ADDRESS :JK�, KOLA CITY/STATE/LIP Zn I 64 J7I $6 C-57 Well Drilling License Number Expiration Date ❑ Bureau of Alcohol,Tobacco and Firearms-Users of High Explosives License Number Expiration Date ❑ CHP Hazardous Material Transportation for Explosives License Number Expiration Date Cl 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 ❑ Repla ment Well ❑ Caaved I ,1❑ Pit Well Inactive ❑ Test Hole Detected/Suspected Well Water Contaminant(s)� gc.4-n.4 Adjacent property with contamination(Address)�j� Known Soil/Water contaminants at adjacent property EXISTING WELLCONSTRUCI'ION DETAILS ❑ Open Bottom ❑ Gravel Pack ❑ Uncased If Other Well Log copy attached 0 Yes ❑ No Grout Seal ❑ No 1111P Yes JT--ft below ground surface(bgs) Hole Diameter_inches Well Conductor Casing O Yes St No Depth of Conductor Casing ft bgs Diameter of Conductor Casing inches Well Casing Diameter_inches Total Depth__tLD ft Depth to Water ft Depth of Casing:�ft bgs DESTRUCTION SPECIFICATION ., Sealing Material from _ft bgs to_ ft bgs Filler Material ;k— —from_ 0 ft bgs to��ft bgs Well casing to be Perforated by one of the following methods: from 0 ft bgs to HO ft bgs ❑ Mills Knife Number of cuts every ft and/or O Explosives ❑ Detonating cord O with projectiles everyft ❑ without projectile O Detonatin Cord and boosted J eX w It proje�t every ft ❑ without projectile Others C1 Li r•r- �G� Sealing Materia[ SQ Neat Cement(94/b bag/5-6 ga/water) ❑ Sand Cement sack mix/7 gal water ❑ Bentonite Pellets ❑ Bentonite(20%solids) O Manufacturer Spec%solids % Name ❑ Specs on File ❑ Specs Submitted Placement Method JA Pumped O Free Fall ❑ Other Seal Completion Ia Complete with Mushroom Cap 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 REQUIRED LICENSE IS CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT 1 AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION LAWS. MININIUM 24 HOUIR ADVANCE NOTICE REQUIREDFOR[NS�/IP�E(`TIONS CONTRACTORSSIGNATURE TITLE CUT, fVLP DATE 65 i �. •...... i.... a....... .. ...... e.. I 1 r s ( �/t DEPARTMENT USE ONLYr� Application Accepted By `f Irl. Date ( ( 1-40 0 Area Destruction Inspection By ��nNte._ -` Date I Z, t Employee ID# COMMENTS PE SC Received Check#/ Amount Date Permit/ Invoice# Well ID# Codes Info B Cash Remitted Service Request# !oD 1 077 p 50 EHD 43-02{XA Well Dti Permit 1/2712005