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WELL DESTRUCTION PERMIT PUBLIC WATER SYSTEM ❑Yes KNo SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 600 E MAIN STREET-STOCKTON CA 95202 -(209)468-3420 NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPE:-- EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS ^," CITY/ZIP CROSS STREET IL AFIN 2'�S 7—.34i —N PARCEL SIZE ;O FANO USE APPLICATION# OWNER ��':�'f \1\1 t V�N1S (� PHONE�„"��— k7 Jy OWNER ADDRESS I lr r (i^k wQ —'aC CITY/STATE/ZIP CONTRACTOR11'1 ae 11i/�S' r1 PHONE CO,NTT,RrACTOR ADDRESS I l q '4 1L. CITY/STATE/ZIP qy C-57 WELL DRILLING LICENSE NUMBER � �� EXPIRATION DATE PERFORATION CONTRACTOR PHONE PERFORATION CONTRACTOR ADDRESS CITYISTATE/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 Sheriff-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 active ❑ Test Hole Detected/Suspected Well Water Contaminant(s) Adjacent property with contamination(Address) Known Sa6lNater contaminants at adjacent property, EXISTING WELL CONSTRUCTION DETAILS ❑ Open Bottom Gravel Pack ❑ Uncased ❑ Other I w' Well Log copy attached ❑ Yes -19[�No Grout Seal 3w,No ❑ Yes It below ground surface(bgs) Hole Diameter inches 1_ Well Conductor Casing❑ Y?s ❑ No Depth of Conductor Casing ft bgs Diameter of Conductor Casing _ inches V Well Casing Diameter inches Total Depth S.V ft Depth to Water _.= ft Depth of Casing _ It bgs DESTRUCTION SPECIFICATION - '+ Sealing Material from ft Dgs to ft bgs Filler Material from ft bgs to _ft bgs r Well casing to be perforated by one of the f011OwinO methods: from ft bgs to _ ft bgs ❑ Mills Knife Number of cuts every ft and/or _ T ❑ Explosives❑ Detonating cord ❑ with projectiles every ft ❑ Without projectile ❑ Detonating cord and boosters ❑ with Projectiles every ❑ Without projectile ❑ Other_.__.____ Sealing Material Neat Cement(941b bag/5.6 gal water)__ Sand Cement sack mix/7 gal waterBentonite Pellets Bentonite(20%solids) - Manufacturer Spec%solids % Name - Specs on File Specs Submitted Placement Method PLmped Free Fall Other Seal Completion ^Complete with Mushroom Cap `F Lt:�..I _3 ft bgs _ Complete to Existing Surface Pad I 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. MINIMUM 2y74�HOUR JJADVANCE NOTICE REQUIRED FOR INSPECTIONS CONTRACTORS SIGNATURE l._/L L !/l..�Z{_['E�.� TITLE (-- t' �s� DATE of ot,i yo�xN tt loot Nbasc NOV 15 ��woA ?011 mor, DEPARTMENT USE ONL Application Accepted By e — _ Date T& Area Destruction Inspection By 7' t' �lC _ Date // /}��ji Employee ID#_�O T� CnMsecNTSi / C t.. s�#2) Tom'll�f/rte T�if E52 PE .'7T/�'C- Sj S Vic._. 1t/h�4JG i/N.ct�JjfLX1?zXT PE SC Retelved Amount Date Permit/ Invoice# WeII1D# Codes Info B h Remitted QService Request# + 373 t 3� 1St'-cam I s/�.a, S 7c I EHO43-M WELL DESTRUCTION PERMIT 10ISM7