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WELL DESTRUCTION PERMIT PUBLIC WATER SYSTEM❑Y-/9k- SAN JOAQUIN COUNTY ENVIRONMENTAL.HEALTH DEPARTMENT 304 E WEBER AVE 3"°FL-STOCKTON CA 95202 -(2099)x`469-3420 NON-REFUNDABLE PERMIT CAL (209)953-7697 FOR I:NsPEc-rlONs XPIRES 1 YEAR FROM DATE ISSUED _y JOBADDRESSAego 1 CITY/ZIP CROSS STREET " APN I' I PARCELSIZE}_01ANDUSEAPPLICATION# o0 OWNER Q ` Tro PHONE_ / — O • 76 17 OWNER ADDRESS / 5, ID �� / CITVISTATE/ZIP /!) /C) i / 72 , CONTRACTOR - l tJvPK4f PHONE CONT OR ADDRESS 6 ' C Q CITY/STATEJZIP -57 WELL DRILLING LICENSE NUMBER O / / EXPIRATION DATE �2 o yr PERFORATION CONTRACTOR PHONE �I PERFORATION CONTRACTOR ADDRESS CITY/STATF/ZIP 9-3 ❑ C-57 Well Drilling License Number Expiration Dale ❑ Bureau of Alcohol,Tobacco and Firearms-Users of High Explosives License Number Expiration Date Cl 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 Nl v REASON FOR DESTRUCTION ❑ Dry ❑ Replacement Well ❑ Caved In ❑ Pit Well M-nactive ❑ Tat 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 fl below ground surface(bgs) Hole Diameter inches Well Conductor Casing ❑ Yes ❑ No Depth of Conductor Casing — "'`- It bgs Diameter of Conductor Casing inches Well Casing Diameter_inches Total Depth ZO p It Depth to Water tl Depth of Casing ft bgs DESTRUCTION SPECIFICATION Seating Material from 100 ft bgs to .3 ft bgs Filler Material from '2-0 y ft bgs to l00 ft bgs Well casing to be perforated by one of the following methods: from ft bgs to ft bgs ❑ Mills Knife Number of cuts every ft and"/"o'r✓ ❑ Explosives ❑ Detonating cord ❑ with projectiles everyft ❑ without projectile ❑ Detonating cord and boosters ❑ with projectiles everyfl ❑ without projectile ❑ Other Sealing Material ❑ Neat Cement(94 Ib hag/5-6 gal waler) Sand Cement .mck mir/7 gal water ❑ Bentonite 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 .3 ft bgs ❑ Complete to Existing Surface Pad I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS. 1 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 LA S. IM M 24 UI-ADV,KNCE NOTICE REQUIRED FOR-ANSPECTIONS CONTRACTORS SIGNATU TITLF BrV /lA DATE t I - -` - — &W-Jo t_Q �« --I— �IALTHOE�IyTT��+Y�•--- - --. - - — X.: -T - Is DEPARTMENT USE ONLY `—J Application Accepted By Dale Area Instruction inspection By �(i„/,-• Date Employee ID# COMMENTS /OG/ ni�i1�-i",w•`"O�IDU ��.. . /VLte.(L. GY r kC��—cam t 3"-1 PE SC Received Amount Date Permit/ Invoice# Well►D# Codes Info B Remitted Service Request# `073 S 6 W r 1 EIID 33-01-OOa Wc0 Doteueh Permit 1 1i21lZWS