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WELL16kiRUCT ON PERMIT PUBLIC WATER SYSTEM ❑Yes ❑No SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 East Hazelton Avenue-STOCKTON CA 95205-(209)468.3420 NON-REFUNDA�1BLrrE__PERMIT 11 CALL 209 953-7697 FOR INSPECTIONS l�EXPIRES C 11 YEAR FROM DATE ISSUED JOB ADDRESS ({U l..J/ uC Pr7. �T-� ��'.' CITYIZIP Y V f I i3 J + +' CROSS STREET �-�� APN •1 UI PARCEL SIZ AND USE APPLICATION# Y rw✓w•� N�.In.f PHONE `IUB hO ��Z-�i� z_ OWNER `] OWNER ADDRESS 0 CITY/STATE/ZIP CONTRACTOR t�N��3 �R'f PHONE �_�-,5 Al')` Y-2- !J.+ u �CONTRACTOR CITY/STATE/ZIP Kw� , }[L C-57 WELL DRILLING LICENSE NUMBER EXPIRATION DATE PERFORATION CONTRACTOR PHONE PERFORATION CONTRACTOR ADDRESS CITY/STATE/ZIP ❑ C-57 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 Shentf-Coroner Explosives Application and Permit License Number Expiration Dale ❑ California Occupational Safety Health-Blaster License Number Expiration Date REASON FOR DESTRUCTION ❑ Dry ❑ Replacement Well in Caved In ❑ Pit Well ❑ Inactive ❑ Test Hole Detected/Suspected Well Water Contaminant(s) Adjacent property with contamination(Address) Known Soil/Water contaminants at adjacent propertv-______ EXISTING WELL CONSTRUCTION DETAILS ❑ Open Bottom ❑ Gravel Pack ❑ Uncased ❑ Other Well Log copy attached ❑ Yes ❑ No Grout Seal ❑ No X.Yes_ ft 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_..YP _ _.inches Total Depth __ It Depth to Water____..___ft Depth of Casing _. It bgs DESTRUCTION SPECIFICATION / Sealing Material from a_v ft bgs to U h bgs Filler Material_.. from ft bgs to It bgs Well casing to be perforated by one of the following methods: from tt bgs to ft bgs ❑ Mills Knife Number of cuts every ft and/or ❑ Explosives ❑ Detonating cord ❑ with projectiles every It ❑ without projectile ❑ Detonating cord and boosters ❑ with projectiles every If ❑ without projectile ❑ Other Sealing Material Neat Cement(941b bag/5-6 gal water)x Sand Cement f0R3 sack mix/7 gal water Bentonite Pellets Bentonite(20%solids) Manufacturer Spec%solids a Name Specs on File Specs Submitted Placement 11ethod Pumped Free Fall Other Seal Completion Complete with Mushroom Cap_ it bgs 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 1 AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION LAWS. 7�,'�lr/�•A•INIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INPEr CTIONS CONTRACTORS SIGNATURE U f irr TITLEy DATE -fir-_ < 7 ff RAI V --r-- ,ECF V AN JOAQUIN COU JT! _ 1_NVIH0ME NTAI. HEALTH DEPAR tMENT D E P A R T M E N T USE ONLY Application Accepted By_ ._. _ Date _ Area Destruction Inspection By Dale 6 Employee ID# 7 COMMENTS 9G[ d 4z , 1 C t C L ryl IT PE SC Received Amount Date Permit/ Invoice# Well ID# Codes Info By 11 Cash Remitted Service Request# 3 ) jl>♦� rw EHD 43-08 WELL DESTRUCTION PERMIT 4130/12