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WELL DESTRUCTION PERMIT PUBLIC WATER SYSTEM ❑Yes ❑No SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 East Hazelton Avenue-STOCKTON CA 95205 - (209)468-3420 NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRE/Sn1 ,YEAR FROM DATE ISSUED JOB ADDRESS Z S Irl CITY/ZIP �1 b0 h t/w 619?w�Y R CROSS STREET -VgAPN ZU 'Z10*O PARCEL SIZE LAND USE APPLICATION# �J Q ,e QA OWNER ( - PHONE `O-1 vnAr b -all 2-27/]G j,/�, m PAH OWNER ADDRESS S -v CITY/STATE/ZIP -W-10G r,7 Ca �F-%_/TJ o � CONTRACTOR I V PHONE -2,09- 2 - I Z CONTRACTOR ADDRESS ' (� (��1 /) CITY/STATE/ZIPMOMW• (1 C-57 WELL DRILLING LICENSE NUMBER �jl W YJ W ZZ EXPIRATION DATE 041301-2,07,1 PERFORATION CONTRACTOR PHONE PERFORATION CONTRACTOR ADDRESS CITY/STATE/ZIP ❑ C-57 Well Drilling License Number Expir ❑ Bureau of Alcohol,Tobacco and Firearms-Users of High Explosives License Number Exp' ❑ CHP Hazardous Material Transportation for Explosives License Number Expiration ❑ San Joaquin County Sheriff-Coroner Explosives Application and Permit License Number Exf**Yn��te ❑ California Occupational Safety Health- Blaster License Number xpiration dte REASON FOR DESTRUCTION ❑ Dry ❑ Replacement Well ❑ Caved In ❑ Pit Well In ole le Detected/Suspected Well Water Contaminant(s) `I��TN n�� Adjacent property with contamination(Address) � TrMFNr Known Soil/Water contaminants at adjacent property EXISTING WELL CONSTRUCTION DETAILS X Open Bottom ❑ Gravel Pack ❑ Uncased ❑ Other Well Log copy attached ❑ YesNo Grout Seal ❑ No ElYes _ft below ground surface(bgs) Hole Diameter -inches Well Conductor Casing ❑ Yes No Depth of Conductor Casing ft bgs Diameter of Conductor Casing inches Well Casing Diameter_ _ inches Total Depth_6o ft Depth to Water 3 __ft Depth of Casing ____,_,_.__ft bgs DESTRUCTION SPECIFICATION Sealing Material from .- _- ft bgs to _ 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 4 Number of cuts every S 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 0 : :1sack mix/7 gal water ❑ Bentonite Pellets Bentonite(20%solids) Manufacturer Spec%solids % Name _ Specs on File ❑ Specs Submitted Placement Method V Pumped Li Free Fall Other Seal Completion omplete 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 I AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION LAWS. MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS CONTRACTORS SIGNATURE TITLE �h DATE ,-Z/ L-_ ........ .._ ... _... �.�o,,S ._... .._�._..... 1. : r II�...�.� I } • E 4=a w S1 `1 _. .__. ...__ ._ _ _. _ . L, - P�s i , : E E ARTMENT USE ONLY Application Accepted By /} Date /_ Area Destruction Inspection By vv✓ �3nV)✓� V��_ Date (�/' Employee ID# COMMENTS _t ( l cA 7� �A 1 PE SC Received Amount Date Permit/ Invoice# Well ID# Codes Info B a emitted Service Request# 3 5 y1 f EHD 43-08 WELL DESTRUCTION PERMIT 4/30/12