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SELL DESTRUCTION PERMIr) A NMED }' PUBLIC WATER SYSTEM D Yes ❑No SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE 3FLOOR-STOCKTON CA 95202 - (209)468-3420 1 NON-REFUNDABLE PERMIT CALL(209)953-7697 FOR INSPECTIONS PIRE 1 YEAR FROM DATE ISSUED I JOB ADDRESS o;— �55 CITYIZIP M OWNER PHONE r%epe-349126 �V7 OWNER ADDRESS 91-' CITYISTATEIZIP / y CONTRACTOR Lc �L PHONE CONTRACTOR ADDRESS119 CITYISTATEIZIP _ 7 __ �Ct1C-$7 WELL DRILLING LICENSE NUMBER r{ L� _EXPIRATION DATE PERFORATION CONTRACTOR PHONE PERFORATION CONTRACTOR ADDRESS CITYISTATEIZIP ❑ 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 ❑ Inactive ❑ Test Hole Detected/Suspected Well Water Contaminant(s): Adjacent property with contamination (Address): Known Soil/Water contaminants at adjacent property: EXISTING WELL CONSTRUCTION DETAIIA Open Bottom ❑ Gravel Pack ❑ Uncased ❑ Other I,, Well Log copy attached 0 Yes No rout Seal ❑ No ❑ Yes ft below ground surface(bgs) Hole Diameter inches Well Conductor Casing ❑ Yes ❑ No Depth of Conduc r Ca Ing ft bgs Diameter of Conductor Casing_inches Well Casing Diameter— inches Total Depth_ ft Depth to Water 44P ft Depth of Casing ft bgs DESTRUCTION SPECIFICATION I Sealing Material from ft bgs to ftbgs Filler Material from ft bgs to ft bgs Well casing to beerf�orat_ed by one of the following methods from fi bgs to ft bgs I ❑ Mills Knife Number of cuts every ft and I or ❑ Explosives ❑ Detonating cord: ❑ with projectiles every ft ❑ without projectile ❑ Detonating cord and boosters: ❑ with projectiles every ft ❑ without projectile ❑ Other Sealing Material ❑ Neat Cement(94 lb bag l S-6 gal water) ❑ Sand Cement sack mix 17 gal water ❑ Bentonite Pellets ❑ Bentonite(20%solids) ❑ Manufacturer Spec%solids % Name ❑ Specs on File ❑ Specs Submitted Placement Method ❑ Pumped ❑ Free Fail ❑ 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. MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS CONTRACTORS SIGNATURE: TITLE: 7� /�I' DATE:G� I UP Ft r idi q CAO, W Re MEN FA T LD PA I. 'E 'r Kr 061 Application Accepted By Date /� —4 � Area � GI Destruction Inspection Date Employee ID# COMMENTS PE SC 'Received Check#! 11 Amount Date Permit/ Invoice# Well ID# Codes Info —By Cash emitted Service Request# G S 4 FHD 43-02-o0R 6/77/04 Well Destruction Permit Addendum 4604 Ic 6-8-04