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•�6oiu ' <br /> DESTRUCTION PERMI',..", <br /> o,V rs/t(f Aft) Zdq- - r _ PUBLIC WATER SYSTEM ❑Yes ❑No <br /> SAN JOAQUIIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304E WEBER AVE 34"FLOOR-STOCKTON CA 95202 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT ��t CALL(209)953-7697 FOR INSPECTIONS EXPIRES I YEAR FROM DATE ISSUED <br /> JOBADDRESS CC Iq 7'' Vr/L �/t CITY/ZIP <br /> OWNER W %'t PHONE - �— C O <br /> '1 O <br /> OWNERADDRESS CITY/STATE//ZZI Q <br /> CONTRACTOR PHONE !r / 79, <br /> CONT CTORADDRE CITY/STATE/ZIP r <br /> C-57 WELL DRILLING LICENSE NUMBER EXPIRATION DATE <br /> PERFORATION CONTRACTOR PHONE <br /> PERFORATION CONTRACTOR ADDRESS CITY/STATE/ZIP <br /> ❑ C-57 Well Drilling License Number Expiration Date <br /> ❑ Bureau of Alcohol,Tobacco and Firearms-Users of High Explosives License Number Expiration Date <br /> ❑ CHP Hazardous Material Transportation for Explosives License Number Expiration Date <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 /> REASON FOR DESTRUCTION ❑ Dry ❑ Replacement Well ❑ Caved In ❑ Pit Well ❑ Inactive ❑ Test Hole <br /> Detected/Suspected Well Water Contaminant(s): <br /> Adjacent property with contamination (Address): <br /> Known Soil/Water contaminants at adjacent property: <br /> EXISTING WELL CONSTRUCTION DETAILS Open Bottom ir Gravel Pack ❑ Uncased ❑ Other <br /> Well Log copy attached ❑ Yes No Grout Seal ❑ No ❑ Yes ft below ground surface(bgs) Hole Diameter inches <br /> Well Conductor Casing ❑ Y s C3_NogDepth of Conductor Casing ft bgs Diameter of Conductor Casing inches <br /> iameter <br /> Well Casing Dinches Total Depth4iVt4V6kd j1 It Depth to Water It Depth of Casing_ft bgs <br /> DESTRUCTION SPECIFICATION <br /> Sealing Material from ft bgs to it bgs Filler Material from ft bgs to It bgs <br /> Well easing to be Derforaled by one of the following methods from ft bgs to It bgs <br /> ❑ Mills Knife Number of cuts every ft and/or <br /> ❑ Explosives ❑ Detonating cord: ❑ with projectiles every It ❑ without projectile <br /> ❑ Detonating cord and boosters: ❑ with projectiles everyft ❑ without projectile <br /> ❑ Other <br /> Sealing Material ❑ Neat Cement(94 lb bag/5-6 gal water) and Cement_/,(_sack mix/7 gal water ❑ Bentonite Pellets <br /> ❑ Bentonite(20%solids�) ❑ Manufacturer Spec%solids % Name ❑ Specs on File ❑ Specs Submitted <br /> Placement Method a kmped ❑ Free Fall 13Other <br /> Seal Completion: M�f cmplete with Mushroom Cap ft bgs ❑ Complete to Existing Surface Pad <br /> 1 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 1 AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> 119�iQ�IC 4 HO ftADIVANCE NOTICE REQUIR FO NSPECTIONS <br /> CONTRACTORS SIGNATUR 4 Ti DATE: <br /> M<}sC(7 <br /> - <br /> 1 <br /> - �ffENS <br /> �i �. - RE�EIV c <br /> !_----- =--�--- --� r-- - - — —. - SAN VIRONM MENS <br /> D ARTMENT USE ONLY f//� <br /> Application Accepted By Date �r �� Area _24 <br /> 3, <br /> Destruction Inspection By Dale Employee ID# <br /> COMMENTS <br /> PE SC Received Checldl/ Amount D PermiU Invoice# WeII ID# <br /> Codes Info Caah Remitte Service R uest# <br /> q <br /> EHD43-02-009 <br /> 6/f W Wcll Dtttrvction Pamir AddcMum 4604 11 M1-N-04 <br />