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`ALL DESTRUCTION PERMI <br /> tPUBLIC WATER SYSTEM ❑Yes No <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> NON-REFUNDABLE PERMIT 304E WEBER AVE 3""FL- <br /> CALL(209)953-7b97 FOR INSPECTIONS )468-3420 <br /> 11 <br /> Jos ADDRESS EXPI M D E ISSUED <br /> . y <br /> CROSS STREET CITY/ZIP <br /> =3 <br /> APN � --'� <br /> OWNER PARCEL SIZEL—LAND USE APPLICATION <br /> v <br /> PHONE �yJ <br /> OWNER ADDRESS � <br /> I <br /> CONTRACTOCITY/STATE/Zip <br /> t <br /> R ) � <br /> CONTRACTOR ADDRESS r PHONE <br /> C-57 WELL DRILLING LICENSE NUMBER Y/STATE/ZIP <br /> / <br /> PERFORATION CONTRACTOR PIRATION DATE <br /> PERFORATION CONTRACTOR ADDRESS PHONE <br /> ❑ C-57 Well Drilling CITY/STATE/ZIP <br /> q Bureau of Alcohol,Tobacco and Firearms-Users of High Explosives License Number <br /> Expiration Date�^ <br /> ❑ CHP Hazardous Material Transportation for Explosives License Number Expiration Date�z <br /> ❑ San Joaquin County Sheriff-Coroner Explosives Application and Permit License Number _ Expiration Date <br /> ❑ California Occupational Safety Health-Blaster License Number Expiration Date_ <br /> License Number Expiration Date <br /> REASON FOR DESTRU ION ❑ Dry Replacement Well <br /> Detected/Suspected Well Water Contamin t(s) ❑ Caved[n ❑ Pit well ❑ Inactive <br /> ❑ Test Hole <br /> Adjacent property with contamination (Address) <br /> Known Sail/Water contaminants at adjacent property <br /> EXISTING WELL CONSTRUCTION DETAILS q Open Bottom <br /> Well Log copy attached q Yes ❑ No GroutSeal [] No ❑ Gravel Pack ❑ Uncased ❑ Other <br /> Well Conductor Casing ❑ Yes ❑ No Depth of Conductor Casln ❑ Yes R below ground surface(bgs} Hole Diameter <br /> inches <br /> Well Casing Diameter >Er inches Total De th g ft bgs Diameter of Conductor Casing_inches <br /> p _Q�ft Depth to Water ft Depth or Casing R bgs <br /> EST UCTI N SPECIFICATION —^�� g <br /> �y <br /> Sealing Material From L S ft bgs to ft bgs Fiber Maters 1 N <br /> Well casing to be erforat d by one of the followin methods: from # I; � from ft bgs to ft bgs <br /> ❑ Mills Knife Number ofcuts eve t•�ft bgs to ^ft bgs <br /> ❑ Expiosives q Detanatin cord every <br /> �—Rand;/'or" <br /> g ❑ with projectiles every ;sft� <br /> ❑ Detonating cord and boosters ❑ with projectiles every_ �� fl <br /> ❑ without projectile <br /> ❑ Other ❑ without projectile <br /> 1 <br /> Sealing Material 13 Neat Cement(94 1b hag/5-t5water al <br /> g ) Sand Cement C'C�- sack mix/7 gal water <br /> ❑ Bentonite(20%solids) q Manufacturer Spec°/a q BentDAlte Pellets <br /> solids % Name <br /> Placement Method 13Pumped ❑ Free Fall ❑ Other ❑ Specs on File 13Specs Submitted <br /> Seal Completion Complete with Mushroom Cap ft bgs:g ❑ Complete to Existing Surface Pad <br /> I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS, n <br /> � <br /> I OUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br /> CONTRACTORS SIGNATUREVr -�, <br /> ITLE DATE <br /> I <br /> _ ._ _ M _�m. _ wC.,_. _ _ _ <br /> ) t I t . _!� _SAN'IOP+QUIN COL1N- .. M <br /> _.._. _ _ <br /> E i i 1 fAL_ <br /> HEAL-TH.DEPP�IiTM <br /> r , ....I_.. ._ - NVIROI�IMENT E!V'1 .._ _. <br /> r <br /> DEPARTMENT USE ONL <br /> 7 <br /> Application Accepted By Date c-3 b r,j <br /> Destruction Inspection By Date !� �i �i mployee ID# 44-006 <br /> 06 <br /> COMMENTS i~ l C-3 zs je -,n --3 t1l' <br /> i <br /> PE SC ReceivedChec Amount Permit/ i <br /> Codes Info B ash Remitted Date Service Request# Invoice# Well IDN <br /> +.3-7:1 161 l M 1_ g asv tn) 3 <br /> EHD 43-02-008 <br /> 1/271204$ Well Destruction Permit } <br /> r <br />