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-$ALL DESTRUCTION PERMIT <br /> y PUBLIC WATER SYSTEM ❑Yes)(No <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE 3"n FLOOR-STOCKTON CA 95262 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT . ' LLCALL(209)953-7697 FOR INSPECTIONS I 'EXPIRES I YEAR FROM DATE ISSUED <br /> JOB ADDRESS ./ Q + /f44J QL- GILA e h 0 CITY/ZIP /v C7 a L <br /> OWNER 1► �_L PHONE „ a <br /> a <br /> �a <br /> OWNER ADDRESS 04 CITYISTATEIZIP <br /> CONTRACTOR kA 6 r`A1S' i Q^ir PHONE <br /> CONTRACTOR ADDRESS dLb CITY/STATE/Zi . V <br /> C-57 WELL DRILLING LICENSE NUMBER -7 <br /> 12fle - EXPIRATION DATE <br /> PERFORATION CONTRACTOR PHONE <br /> PERFORATION CONTRACTOR ADDRESS CITY/STATEIZIP <br /> ❑ C-57 Well Drilling License Number Expiration Date <br /> ❑ Bureau of Alcohol,Tobacco and Firearms-Users of High Explosives License Plumber Expiration Date <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 O <br /> ❑ California Occupational Safety Health-Blaster License Number Expiration Date. <br /> REASON FOR DESTRUCTION ❑ Dry ❑ Replacement Well ❑ Caved In ❑ Pit Well ,%<Inactive ❑ Test Hole <br /> Detected/Suspected Well Water Contaminant(s): <br /> Adjacent property with contamination (Address): <br /> Known Soil/Water contaminants at adjacent property: <br /> EXISTING WELL CONSTRUCTION DETAILS Open Bottom ❑ Gravel Pack ❑ Uncased ❑ Other <br /> Well Log copy attached ❑ Yes�No Grout Seal [3 No [I Yes ft below ground surface(bgs) Hole Diameter inches. <br /> Well Conductor Casing ❑ Yes No Depth of Conductor Casing ft bgs Diameter of Conductor Casing _niches: <br /> Well Casing Diameter inches Total Depth ft Depth to Water—4—ft Depth of Casing ft bgs <br /> DESTRUCTION SPECIFICATION <br /> Sealing Material from . �ft bgs to ft bgs Filler Material from ft bgs to ft bgs <br /> Well 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 fl ❑ without projectile <br /> ❑ Detonating cord and boosters: ❑ with projectiles every ft ❑ without projectile <br /> ❑ Other <br /> Sealing Material ❑ Neat Cement(94 Ib bagl5-6 gal wafer) ❑ Sand Cement sack mix/7 gal water Bentonite Pellets <br /> ❑ Bentonite(20%solids) ❑ Manufacturer Spec%solids % Name ❑ Specs on File ❑ Specs Submitted <br /> Placement Method ❑ Pumped Free Fall ❑ Other <br /> Seal Completion: -AK Complete with Mushroom Cap `L ft bgs ❑ Complete to Existing Surface Pad <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/U4.2244 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br /> CONTRACTORS SIGNATURE: Awn, TITLE: �/' DATE:/I-L3 -0s <br /> 4/4 Ara <br /> O <br /> VIR . -Ulm <br /> . <br /> H i <br /> Q <br /> DEP RTMENT USE ONLY <br /> Application Accepted By Date Area �l <br /> Destruction Inspection By Date '� C5G Employee 1Di# .S346rb r <br /> COMMENTS —UZ1— <br /> r <br /> PE SC Received Check#1 Amount Date Permit/ Invoice# Well ID# <br /> Codes Info B ash Remitted Service Request# <br /> y <br /> END 43-02-OOK _ - <br /> &744 Well Destruction Permit Addendum 4604 Ic 6-9-04 <br />