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�O WELL DESTRUCTION PERMIT PUBLIC WATER SYSTEM []Yes ONO SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 600 E MAIN STREET-STOCKTON CA 95202-(209)468.3420 NON-REFUNDABLE PERMIT C LL 209 5 4697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED /y v JOB ADDRESS CITY/ZIP CROSS STREET L-'4 { _ N 21 Z— - 3�- PARCEL SIZE(4_7'Gw USE APPLICATION# OWNER PHONE OWNER:ADD V CRY/S TTjTEIZIP CONTROR I /!L PHONH C OR ADDRE . CrrvtSTATFJZIP C 57 WELL DRILLING LICENSE NUMBER EXPIRATION DATE P TION CONTRACTOR PHONE PERFORATION CONTRACTOR ADDRESS CITYISTATE/ZIP ❑ C-57 Well Drilling License Number Expiration Date ❑ Bureau of Alcohol,Tobacco and Firearms-Users of High Explosives License Number Expiration Date O 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 DESTRUCTLON ❑ Dry ❑ Repiacement 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 W Well Log copy attached ❑ Yes es-/NNo Grout Seal No ❑ Yes ft below ground surface(bgs) Hole Diameter inches Well Conductor Casing❑ Yes &,No Depth of Conductor Casing ft bgs Diameter of Conductor Casing inches r^ well Cuing Dlamebrr inches Total Depth Depth to Water_ ft Depth of Casingf!-�_ft bgs _1 DESTRUcT10N SPECIFICATION Sealing Material from[OTI-,PA_R bgs to:�W_ft bgs Filler Material from. ft bgs to ft bgs Well casing to be perforates!by one of the following methods: from ft bgs to ft bgs ❑ Mills Knife Number of cuts every -.. ._ ft and/or ❑ Explosives❑ Oetonating cord ❑ with projectiles every ft ❑ without projectile ❑ Detonating cord and boosters ❑ with projectiles everyft ❑ without projectile ❑ Other-- S ther-- Sealing Material D Neat Cement(94 ib bag/5-6 gal water)n Sand Cement sack mix/7 gaiter ❑ Bentonite Pellets p7 Bentonite(20%solids) 7 Manufacturer Spec%solids_% Name (��dll lI/F1� /�G C/Specs on File ❑ Specs Submitted r Placement Method C Pumped LJ Free Fall 7 Other Seal Completion�Complete with Mushroom Cap 3 It bgs n Complete to Existing Surface Pad fN` 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. M 4H 42 ADVANCE NOTICE REQUIRED FO INSPECTIONS CONTRACTORS SIGNATURE TITLE Dar ,c�t C. L. . �/ UAW- •r-4-. ( .t I I I 4. j r + _¢ _ _ v I , ►- } " FEB 2 6±2009 - t {•-f- --I + ffOl�sE-• I - SAN JOAQUIN COUNTY. I. t.-}...�. r ...� 4- 1__+--r—+-a a•-+-��- -�-�-•-�ENVIiTONMENTAL ,F- - T- I i (1EAl TH DEPARTMENp ( 4 .F . * t ! ! ! f l D E P A R-T-M-E-N T--U S E—O N L Y- - -----� +•� - - -- 3 - Application Accepted By Date :-Zz&[/y� Area /9 9 Destruction Inspection L�� l�q Employee ID# COMMENTS �,y/E!D f� 1Y ivy./I Gll7 G /r� /iT//�/4 ',•Q� Z' eo�--2 rte'}�r�+.�zb Ct.E�GI I PE SC Received ec Amount Date Permit/ v T Invoice# WoilID# Codes Info By Cash Remitted Service Request# 4-3-7 3 r(.1 515 2 so.o t} or o1 13kQ'05494215 I EHD 43-08 WELL DESTRUCTION PERMIT 1016/07