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,7,LL DESTRUCTION PERMI' <br /> a PUBLIC WATER SYSTEM ❑Yes 9 No <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT X I + t 304 E WEBER AvE 3""FLOOR-STOCKTON CA 95202 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL(209)953-7697 FOR INSPECTIONS EXPIRES I YEAR FROM DATEISSUED <br /> JOB ADDRESS ,/TYlZ1P �� m <br /> OWNER 241 <br /> — �- "]tHONE - � p <br /> d <br /> OWNER ADD [-ZSR CITYISTATE/ZVO— <br /> PERFORATION <br /> r r � <br /> CONTRACTOR Q / PHONE <br /> CONTRACTOR ADD S CITY/STATE/Z <br /> v---C-57 WELL DRILLING LICENSE NUMBER I EXPIRATION D <br /> CONTRACTOR PHONE <br /> PERFORATION CONTRACTOR ADDRESS CITYISTATEIZIP <br /> i <br /> t <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 /> i <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 aved In J it ell ❑ Inactive ❑ Test Hale <br /> Detected/Suspected Well Water Contaminant(s): <br /> f Adjacent property with contamination (Address): <br /> Known Soil/Water contaminants at adjacent property: <br /> EXISTING WELL CONSTRUCTION DETAILS,,,D <br /> Open Bottom ❑ Gravel Pack ❑ Uncased Other <br /> Well Log copy attached El Yes hfoGrout Seal ❑ No ❑ Yes ft below ground surface(bgs) Hole Diameter inc s . <br /> Well Conductor Casing ❑ Yes ❑ No Depth of Conductor Casing ft bgs Diameter of Conductor Casing,. inches <br /> Well Casing Diameter inches Total Depth ft Depth to Water it Depth of Casing it bgs <br /> Y <br /> DESTRUCTION SPECIFICATION <br /> Sealing Material from ftbgs to ft bgs Filler Material from ft bgs to it bgs <br /> Weil casing to be Perforated by one of the following„methods from ft bgs to ft bgs <br /> Mills Knife Number of cuts every ft and/or <br /> ❑ Explosives ❑ Detonating cord: ❑ with projectiles every ft ❑ without projectile <br /> ❑ Detonating card and boosters: 13with projectiles every ft ❑ without projectile <br /> ❑ Other �f <br /> Sealing Material ❑ Neat Cement(94 lb bag 15-6 gal water) and Cement-IZL-Ipsack mix/7 gal water ❑ Bentonite Pellets <br /> ❑ Bentonite(20%solids) ❑ Manufacturer Spec%solids % Name ❑ Specs on File ❑ Specs Submitted <br /> Placement Method ❑ P ped C3 Free Fall ❑ Other ry�� <br /> Seal Completion: Complete with Mushroom Cap ft bgs ❑ Complete to Existing Surface Pad I <br /> 1 <br /> I HEREBY CERTIFY THAT I 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 I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> MINIM 24 H UR ADV NCE NOTICE REQUIRED FOR IPEC IONS <br /> CONTRACTORS SIGNATURE: TITLE: G DATE: <br /> _r <br /> - J <br /> ln <br /> J. <br /> l e <br /> DEPARTMENT USE ONLY >tL <br /> Application Accepted By Date, Area I C <br /> Destruction Inspection By Date f�d� a� Employee]D#- <br /> COMMENTS <br /> PE SC Received hec Amount Date Permit/ Invoice# Well ID# <br /> Codes Info B ash Remitted Service Re uest# <br /> 43:7-{ r4 s .2sG c* a� 7 1-12 <br /> END 43-02-008 <br /> rd7iO4 Well Destruction Pcrmii Addendum 4604 Ie 6-8-04 <br />