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`ELL DESTRUCTION PERMI" ZR AMNLU I' v PUBLIC WATERSYSfEM ❑Yes ❑No SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE 3"FLOOR-STOCKTON CA 95202 - (209)468-3420 NON-REFUNDABLE PERMIT CALL(209)9553-76977`FOR INSPECTIONS EXPIRES 1-YEAR FROM DATE ISSUED JOBADDRESSbl pg nG 0-f./ /ZIP GLC /` m OWNER R ONE dal_—"Y0202--( 'Z(�J�% lir(� xO OWNER ADDR D �� CITY/STATE/ZIPV�✓` C_ J"�•—r � , • /✓�-�L N CONTRACTOR �J� J I PHONE / "Zi7 y CONT OR ADDRESS W K CITY/STATE/ZIP 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 Sheriff-Coroner Explosives Application and Permit License Number Expiration Date ❑ California Occupational Safety Health-Blaster License Number Expiration Date REASON FOR DESTRUCTION ❑ Dry Jp9lac ell ❑ Caved In ❑ Pit Well ❑ Inactive ❑ Test Hole Detected/Suspected Well Water Contamioant(s): Adjacent property with contamination (Address): !n Known Soil/Water contaminants at adjacent property: I EXISTING WELL CONSTRUCTION DETAILS 13Open Bottom Gravel Pack ❑ Uncesed 13Other Well Log copy attached [I9 Yes ryn Grout Seal ❑ No ❑ Yes It below ground surface(bgs) Hole Diameter inches Well Conductor Casing ❑ Yes ErNo Depth of Conductor Casing ft bgs Diameter of Conductor Casing inches: Well Casing Diameter inches Total DepthVu�V�/ ft Depth to Water ft Depth of Casing ft bgs DESTRUCTION SPECIFICATION _ Sealing Material from AM _ft bgs to ft bgs Filler Material from ftbgs to a N ft bgs 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 1 ❑ Explosives ❑ Detonatingcord: ❑ with projectiles every ft ❑ without projectile ❑ Detonating cord and boosters: ❑ with projectiles every ft ❑ without projectile ❑ Other Sealing Material ❑ Neat Cement(94 lb bag/5-6gal wafer) Sand Cement sack mix/7 gal water ❑ Bentonite Pellets ❑ Bentonite(20%solid/s)) ❑ Manufacturer Spec%solids % Name ❑ Specs on File ❑ Specs Submitted Placement Method QIP ped ❑ Free Fall ❑ Other Seal Completion: Complete with Mushroom Cap 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. MINI 4 OUR DANCE NOTICE REQUIRED FOR NSPECTIONS CONTRACTORS SIGNATURE: TITLE' DATE: l r O R M E Application Accepted By L Date 7/t1.At7Q Area Destruction Inspection.,y y� Date �%''��"r'J Employee ID# r COMMENTS 7 �O .�5 / t.(//fM,2'%� /2g�/!/�� /4 4! �f{ti9.DlJ�'D f!I �4lSP LD PE SC 'Received eck# Amount Date Permit/ Invoice# Well ID# Codes Into ash Remitted Service Re ueat# Zy END 43-0LWA N11D1 Well rmvY[Ibn Permit Addendum 4IA4 is b8,04