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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 EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS CITY/ZIP CROSS STREET -APN ` '_ nI O/ 3 PARCEL SIZE- LAND USE APPLICATION# OWNER ��/ O Aa- PHONELon m OWNER ADDRESS n, CITY/STATE/ZIP CONTRACTOR �D/cam// l PHONE CONTRACTOR ADDRESS v CITY/STATE/ZIP -57 e�f ❑ C-57 WELL DRILLING LICENSE NUMBER / EXPIRATION DATE PERFORATION CONTRACTOR PHONE PERFORATION CONTRACTOR ADDRESS CITY/STATE/ZIP ❑ 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 ❑ 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 ❑ No Grout Seal ❑ No ❑ Yes_ ft below ground surface(bgs) Hole Diameter inches Well Conductor Casing ❑ Y sK❑ No Depth of Conductor Casing ft bgs Diameter of Conductor Casing inches Well Casing Diameter_ inches Total Depth_ - ft Depth to Water ft Depth of Casing ft bgs DESTRUCTION SPECIFICATION Z Sealing Material from ft bgs to ft bgs Filler Material from ft bgs to t bgs Well casing to be perforated by one of the following methods: from It bgs to ft bgs ❑ Mills Knife Number of cuts every_ ft and/or .?�7 -Afl�M-U45n-3 ❑ 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/1 gal waterntonite Pellets Bentonite(20%solids) Manufacturer Spec%solids % Name Specs on File Specs Submitted Placement Method Pumped Free Fall Other Seal Completion Complete with Mushroom Cap ft bgs i 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. uQ MI Iv E NOTICE REQUIRED FOR INSPECTIONS CONTRACTORS SIGNATURE '� TITLE /�;g"/�" DATE 427 i ... _ --... ..........- -------- .................. ................... — 4 ls-r` { — a — -I i I -12019 � SAN JOAQUIN COUNTY ...._............... .....___-.._ �. _...-.-.- _-. --_..._I _..__._.-_ ..-...__ _..._._.._.... _... .. _ - --.; ENV1RONh1ENTAL i HEALTH DEPARTMENT PARTMENT USE ONLY Application Accepted By Date Area S Destruction Inspection By Date 7Z EEloyee ID# COMMENTS e-C— PE SC Received Check#/ Amount Permit/ Codes Info B Cash Remitted Date Servi a uest# Invoice# Well ID# 1;73 A 15-9 3 I r- EHD 43-08 WELL DESTRUCTION PERMIT 4/30/12