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SL,,,, Id-0- Ib I�s� WELL DESTRUCTION PERMIT PUBLIC WATER SYSTEM ❑Yes ❑No SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 East Hazelton Avenue-STOCKTON CA 95205-(209)468-3420 NON-REFUNDABLE PERMIT, �7 CALL 209 953-7697 FOR INSPECTIONS EXPIRES I YEAR FROM DATE ISSUED JOB ADDRESS E CnrZP�/�. a CROSS STREET SC.1�.>� . APN ,�'rl I G(V PARCEL SIZE�LANO USE APPLICATION# OWNER 0" ' rm-"0, i1C.l� :N PHONE �1G - 1I� — 01��aC'j T OWNERADDREESVSS--IqG CA C I �1 Qk CITY/STATTEEj/ZIPCa CONTRACTORI�P'��..�L.Y ^QI.UY�O r VJyk( ' l PHONE -S ,- 7� CcarrRACTOR ADDRESS CITY/STATE/ZIP V4161i7 01 C-57 WELL DRILLING LICENSE NUMBER 3V 5q EXPIRATION DATE U /311• L I PERFORATION CONTRACTOR PHONE PERFORATION CONTRACTOR ADDRESS CrTYISTATE/ZIP eft 1jriHintT 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 DESTRUCTION X Dry I L Replacement 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 Well Log copy attached ❑ Yes ). No Grout Seal ❑ No ❑ Yes it below ground surface(bgs) Hole Diameter inches Well Conductor Casing❑ Yes t� No Depth of Condµ1ctor Casing It bPs./� Diameter of Conductor Casing inches Well Casing Diameter_ �.v inches Total Depth.�V �it Depth to Water,3PQ/; ft Depth of Casing ft logs DESTRUCTION SPECIFICATION rr �� Sealing Material from ! it bgs to _ L'____ It bgs Filler Material lJ'�'" _from - It bgs to •..'.___.ft logs Well casing to be perforated by one of the following methods: _. . from ft bgs to.. it 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 ft ❑ without projectile ❑ Other Sealing Material Neat Cement(941b bag/5-6 gat water) Sand Cement l O� —sack mix/7 gal water Bentonite Pellets Bentonite(20%solids) Manufacturer Spec%solids o Name Specs on File Specs Submitted F•lacement Method 7� 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 I AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION LAWS. MINIMUM 24 HOUR ADVANCE NOTICE REOUI D FOR INSPECTIONS CONTRACTORS SIGNATU / C v I� TITLE" L v "DATE �.., _. (_J DEPARTMENT USE ONLY/ Application Accepted By _ Date 'a S` Area 2 1��1 r"S"P`��'L Destruction Inspection By a Date Employee ID# COMMENTS 7J v p�6 PESC Received Check#/ Amount Perm iU p� Codes Info B Cash Remitted Data Service Re est k Invoice# W # X N 1 % S JOP OM PPt Ll 0-7 EHD 43-09 WELL DESTRUCTION PERMIT 4/30/12