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'ELL DESTRUCTION PERMI1 <br /> PUBLIC WATER SYSTEM ❑Yes 17p No <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE 3°n FLOOR-STOCKTON CA 95202 - (209))4\68-3420 <br /> NON-REFUNDABLE PERMIT CALL(209)953-7697 FOR INSPECTIONS EXPIRES I YEAR FROM DATE ISSUED <br /> / n w <br /> JOB ADDRESS / Q LOW Qt- GIS' O EN CITY/ZIP H Ir �/ d' m <br /> OWNER - J{Ale gll./ IS'.."/ PHONE- o <br /> OWNER ADDRESS y��p� Dili CITY/STATE/ZIP <br /> CONTRACTOR /�!n/i PHONE _ "172-r <br /> Jn <br /> CONTRACTOR ADDRESS G � CITY/STATE/ZI�/6`✓9�W b <br /> C-57 WELL DRILLING LICENSE NUMBER <br /> EXPIRATION DATE 'U—0 / <br /> PERFORATION CONTRACTOR PHONE <br /> PERFORATION CONTRACTOR ADDRESS CITY/STATE/ZIP <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 /> ❑ CHP Hazardous Material Transportation for Explosives License Number Expiration Date O <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 ❑ 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 ❑ YesNo Grout Seal ❑ No ❑ Yes II below ground surface(bgs) Hole Diameter inches <br /> Well Conductor Casing ❑ Yes No Depth of Conductor Casing ft bgs Diameter of Conductor Casing inches <br /> Well Casing Diameter inches Total Depth It Depth to Water_ _ft Depth of Casin¢ ft bgs f <br /> DESTRUCTION SPECIFICATION V1 <br /> Sealing Material from _/ ft bgs to —j ft bgs Filler Material from ft bgs to ft bgs <br /> Well casing to be Derforated by one of the following methods from ft bgs to R 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: ❑ With projectiles everyft ❑ without projectile <br /> ❑ Other <br /> Sealing Material ❑ Neat Cement(94 Ib bag/5-6 gal water) ❑ Sand Cement sock mix/7 gal water Bentonite Pellets <br /> ❑ Bentonite(20%wilds) ❑ Manufacturer Spec%solids % Name ❑ Specs on File ❑ Specs Submitted <br /> Placement Method ❑ Pumped Free Fall ❑ Other <br /> Seal Completion: ,;I< Complete with Mushroom Cap 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 /> MINIMUN1.j2244 HOUR ADVANCE NOTICE REQUIRED/ / <br /> FORINSPECTIONS <br /> v / <br /> CONTRACTORS SIGNATURE: / �'^-^f0 e'!!W Y-� TITLE: W�K� DATE:S �_ <br /> J <br /> -r C ' , AYMENT <br /> 22 <br /> _ SAN JOA a 1N COUNfy <br /> '�_.. <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> _ _ .. <br /> l <br /> — .L--r-- � . <br /> DEP9RTMENT USE ONLY <br /> Application Accepted By �IfFi 2 �_ 6�/L Date Area <br /> Destruction Inspection By Dates O� Employee ID# <br /> COMMENTS —U? -- <br /> Glc <br /> PE SC Received Check#/ I Amount Date Permit/ Invoice# Well ID# <br /> Codes lnfoi By as I Remitted Service Request# <br /> EHD 41-02-00a <br /> &7,04 Well Destruction Permit Addendum 4604 Ic 6-H-M <br />