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- '-"' .-- • •.-I—I-1"`— "^`•'^" I 186a East Hazelton Avenue-STOCKTON CA 95205-6232 -(209)468-3420 NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONiS EXPIRES 1 YEAR FROM DATE ISSUED n JOB AooREss�z[3'�cj( I� -e CNC YC'M1`0 CITY/LP CROSS STREET. 12, � e r- T7 APN PARCEL SIZE' 'J LLAND USE APPLICATION# O 7 / 0 OWNER PHONE J OWNER ADDRESS SMC CITY/STATE/LP �+ CONTRACTOR (C Y�,r PHONE j C r l - 2_] /C,f CONTRACTOR ADDRESSr- Y CITY/STATE/ZIP CI - /\ C-57 WELL DRILLING LICENSEI /�NUMBER -2 q q 5` 3 EXPIRATION DATE 7 PERFORATION CONTRACTOR ' (.• r / '�C l•1 I �, CI Y) J f'" t� C PHONE '-i I L -70 - C) PERFORATION CONTRACTOR ADDRESS ( Ylf�f'S r'1 V CITY/STATE/7JP_3Q f f S i e'r1T to 7� 1 ❑ 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 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 )8 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 DETAILS Open Bottom Gravel Pack ❑ Uncased ❑ Other __ Well Log Copy attached ❑ Yes 19 No Grout Seal ❑ No I& Yes Ivl A _ft mebelow ground surface(bgs) Hole Diater_inches Well Conductor Casing❑ Yes �11, No Depth Of Conductor Casing IT bgs Diameter of Conductor Casing inches Well Casing Diameter 'ti inches Total Depth _ft Depth to Water ft Depth of Casing---:. _ P g� -_It bgs DESTRUCTION SPECIFIC"ATION -� Sealing Material from _ X� ft bgs to_�ft bgs Filler Material S� & from ft bgs to_ U ft bps Well casing to be perforated by one of the following method _from ft bgs to__ft bgs ❑ Mills Knife Number of cuts every ft and/or 79 Explosives❑ Detonating cord ❑ with projectiles every ft ❑ without projectile Other ❑ Detonating cord and boosters 11 with projectiles every _ ft ❑ without projectile ❑ Sealing Material Neat Cement(94 lb bag/5-6 gal water) Sand Cement-J(� ;�_ sack mix/7 gal water Bentonite Pellets Bentonite(20%solids) Manufacturer Spec%solids_% Name Specs on File Specs Submitted Placement Method x Pumped Free Fall Other Seal Completion Complete With Mushroom Cap C ft bgs x 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 48 HOUR ADVANCE f�9O OCE REQUIRED FOR INSP(ECTI(ONS CONTRACTORS SIGNATURE_ /� / 4� TITLE �� ( � I�f } DATE ----------------- t f ( I C') d DEPARTMENT USE ONLY Application Accepted By Dale Area Destruction Inspection By Date Employee IDS COMMENTS PE SC Received Check#/ Amount Permit/ Codes Info B rm Cash Remitted Date Service rm / # Invoice# Well ID# EHD 43-0e revised 4114118 WELL DESTRUCTION PERMIT