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1?�7" WELL DESTRUCTION PERMIT PUBLIC WATER SYSTEM❑Yes/16 es No SAN JOAOUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE 3'FL-STOCKTON CA 95202 -(209)468-3420 NON-REFUNDABLE PEkMq C, .L(289)953-7697 FOR IIKSPEC71oNS EXPIRES I YEAR FROM DATE ISSUED JOB ADDRESS CtTY1ZIP N CROS SA APN t� -GI I- PARCEL$1ZE r7 77 AND EJSE APPLICATIONS o A OWNER PHONE y OWNER ADDRES l� CITYIST TpEIZI CONTRACTOR a �• PHONE W CONTRACTORADDRES `` CITYISTATEIZIP -,l!r'C-57 WELL DRILLING LICENSE NUMBER 1 EXPIRATION DAT. 9 PERFORATION CONTRACTOR PHONE PERFORA ]ON CONTRACTOR ADDRESS CITYISTATEIZIP 1 -57 Well Drilling License Number Expiration Date ❑ Bureau of Alcohol,Tobacco and Firearms-Users of High Explosives License Number Expiration Irate ❑ CHP Hazardous Material Transportation for Explosives License Number Expiration Date ❑ San Joaquin County ShcrifT-Coroner Explosives Application and Permit License Number Expiration Date ❑ California Occupational Safety Health-Blaster License Number_ Expiration Date REASON FOR DESTRUCTION ❑ Dry ❑ Replacement Well ❑ Caved In ❑ Pit Well Inactive ❑ Test Hole Detected I Suspected Well Water Contaminant(s) Adjacent property with contamination(Address) Known Sail I Water contaminants at adjacent property (STING WELL fONucTioN DETAILS ❑ Open Bottom ❑ Gravel Pack ❑ Uncased OtherV R' fAE� W Well Log copy attached ❑ YesNo Grout Scal 13No ❑ Yes fibelow ground surface(bgs) Hole Diameter inches Well Conductor Casing ❑ Yes P-"No Depth of Condo or ing ft bgs Diameter aFCanductor Casing inches Well Casing Diameter_inches Total Depth ft Depth to Water ft Depth of Casing ft bgs t DESTRUCTION SPECIFICATION Sealing Material from/-�Fl bgs to !7r14 R bgs Filler Material ,$�I((Q �fromA%120�f-,R bgs to-,JA0A ft bgs Wasing to be perforated by one of Ih f 11 in methods: from ft bgs to fl bgs Mills Knife 1 co Fr`S�uni o cvtts every S— R and 1 or Well ❑ Detonating cord Q with projectiles every ft ❑ without projectile ] ❑ Detonating cord and boosters ❑ with projectiles everyft ❑ without projectile ❑ Other Sealing Material ❑ Neat Cement(941h hag/5-b gal water) Sand Ccment xack mix 17 gal water ❑ Bentonite Pellets ❑ Bentonite(20 Y lids) ❑ Manufacturer Spec%solids_% Name ❑ Specs on File ❑ Specs Submitted Placement Me[hod L7 Pumpc l ❑ Frec Fall ❑ Other I Seal Completion Complete with Mushroom Cap ft bgs ❑ Compiete to Existing Surface Pad [ 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. 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. N)I NLI NI�V M Y4 HO ADVANCE NOTICE.REQUIRED FW INSPECTIONS CONTRACTORS SIGNATURE TITLE DATE f 0� PAYMENT RECE4�1 F�' LI'6u"' MAR 0 3 2066 ® Spy sonouw cauN ter ENVIRON()ENTAL HEAITFt DEPFRYMEt+iT Y / DEPARTMENT USE ONLY — -- - Application Accepted By Date N �,�� Area Destruction Inspection By Dace O Employee IDN COMMENTS 126 l f i PE SC Received Check# Amount Date Permit/ Invoice N Well IDN Codes Info B emitted Service Re uest N 3 0