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WELL DESTRUCTION PERMIT PUBLIC WATER SYSTEM ❑Yes SAN JOAQIIIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 600 E MAIN STREET•STOCKTON CA 95202-(209)4683420 NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED Joe ADDRESS r�2�� W. Cee -Z 441,f' CRYZP= 1eJ(-4V CROSS STREET LA-M ,I><Q-c APN 20—044 '(2�2 PARCEL ,SLZEE-ST LANo USE APPLICATION# OWNER—A(/5--r—IAT 41mi f p 71/F..k�H/ PHONEry�ys-a-lafa OWNER ADDRESS SD :{2-1C 66 4.z� ,/l-/) CITY/STATEZP A & 4,�D� CA CONTRACTOR ��77 R 2W(AA-/nn-IA15— J !- PHONE 46:7-7452 CONTRACTOR ADDRESS ,7�k�( a CITY/STATE7ZIP-r41,C40Ce 7d-9,0_ 0--C-57 WELL DRILLING LICENSE NUMSER �L a EXPIRATION DATE PERFORATION CONTRACTOR PHONE PERFORATION CONTRACTOR ADDRESS CITYISTATEIZIP ❑ C-b-7 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 DEsTRUcnoN ❑ Dry ❑ Replacement Well ❑ Caved In ❑ Pit Well Inactive ❑ Test Hole Detected/Suspected Well Water Contaminants) Adjacent propertywith contamination(Address) Known Soil/Water contaminants at adjacent property _ [ ExISnNG WELL CONSTRUCTION DETAILS O Open Bottom 13 Gravel Pack ❑ Uncased ❑ Other nnn Well Log copy attached ❑ Yes EYNo Grout Seal R No ❑ Yes ft below ground surface(bgs) Hole Diameter inches `tom Well Conductor Casing❑ Yes Er"No Depth of Conductor Casing h bgs Diameter of Conductor Casing inches 1� Well Casing Diameter inches Total Depth_gS:j�.7 ft Depth to Water_fJ�_ft Depth of Casing R bgs C DESTRUCTION SPECIFICATION Sealing Material from [L ft bgs to:2W ft bgs Filler Material from it bgs to 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 k and/or [ ❑ Explosives❑ Detonating cord ❑ with projectiles everyft ❑ without projectile ❑ Detonating cord and boosters ❑ with projectiles every_-- it ❑ without projectile ❑ other Sealin Material C Neat Cement(941b bag/5.6 gal water)0 Sand Cemant sack m&17 gal water 0 Bentonite Pellets Bentonite(20%soil ) 0 Manufacturer Spec%solids_% Name T. �G� D,- ; specs on File ❑ Specs Submitted Placement Method Pumped C Free Fall (-I Other Seal Completion &--6mplete with Mushroom Cap ft bgs C 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. 1�IM 24 OUR ADVANCE NOTICE REQUIRED F INSPECTIONS CONTRACTORS SIGNATUREZ " TITLE DATE I ! u ► _.,._ _ -4 PAYMENT RECEIVE t- + t �,. 4.. -pFC r -.2008_ ir r s .-t. +. + SAN JOAQUIN COUNTY -+Tt -7'—'i-A- '4 - -*'t-- �— — �- t- I f ` } �I•II;ALT1-I DEPMAENViFlONRTMENT DEPARTMENT USE ONLY Application Accepted By Date 2 ( CJ Area Destruction InspectionS Date OS Employee ID#_ �S COMMENTS PE SC Received heck Amount Date permW Invoice# Well ID# Codes Info By_ Cash Remitted Service Re uest# EMO 43-08 WELL DESTRUCTION PERMIT 1015W