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SELL DESTRUCTION PERNH- %v.! ►►►...,,,rrr\N PUBLIC WATERSVSI'EM ❑Yes Dp o SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE 3R"FLOOR-STOCKTON CA 95202 - (209))468-3420 NON-REFUNDABLE PERMIT I' . '•CALL(209)953-76197 FOR INSPECTIONS EXPIRES I YEAR FROM DATE ISSUED JOB ADDRESS / o R a.tJ ffa�!/1"' GIL 6f` O CITY/ZIP 0 (/ 6' OWNER �NJ rt �e AA 4J *yf/ PHONE y �s 'e OWNER ADDRESS CITY/STATE/ZIP Lk CONTRACTOR LA /WnnRO � PHONE--93 - L— J��J CONTRACTOR ADDRESS G 'tet CITY/STATE/ZIz4'-4W�✓O'-]�W 6 C-57 WELL DRILLING LICENSE NUMBER )17 2 S EXPIRATION DATE 'U 0 / 7 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 O ❑ 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 DETAILS Open Bottom ❑ Gravel Pack ❑ Uncased ❑ Other Well Log copy attached ❑ Yes No Grout Seal ❑ No ❑ Yes ft below ground surface(bgs) Hole Diameter inches Well Conductor Casing ❑ Yes No Depth of Conductor Casing ft bgs Diameter of Conductor Casing inches Well Casing Diameter inches Total Depth it Depth to Water--6--ft Depth of Casing ft bgs DESTRUCTION SPECIFICATION Sealing Material from _ / _.ft bgs to_ R bgs Filler Material from ft bgs to ft bgs Well casing to be perforated by one of the following methods from ft bgs to ft bgs ❑ Mills Knife Number of cuts every ft and/or ❑ Explosives ❑ Detonating cord: ❑ with projectiles every it ❑ without projectile ❑ Detonating cord and boosters: ❑ with projectiles everyft ❑ without projectile ❑ Other Sealing Material ❑ Neat Cement(94 1b bag/5-6 gal water) ❑ Sand Cement sack mix/7 gal water I>cBentonite Pellets ❑ Bentonite(10%solids) ❑ Manufacturer S ec%solids_% Name ❑ Specs on File 13 Specs Submitted Placement Method Cl Pumped ree Fall ❑ Other Seal Completion: r< 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. 1 ALSO CERTIFY THAT MY REQUIRED LICENSE IS CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT 1 AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION LAWS. MINIMU 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS /�JJ CONTRACTORS SIGNATURE: A �w, ' TITLE:vWJ#-�— DATE: T—2J PAYIVIENf EI N 0 1 2000 A/6 US/ SAN SAN JOAQUIN COUNTY -J �" --- i G ENVIRONMENTAL -- - '-- — HEALTH DEPARTMENT DEPRUSE ONLY Application Accepted By Date � Area � �( Destruction Inspection By Date /�5�� Employee Destruction ,536 COMMENTS ^U2� PE SC SC Received Check#/ Amount Dara Permit/ Invoice# Well ID# Codes Info By as Remitted Service Request# S e D S" S37 EHD 43-02-009 Well Damuction Permit Addendum 4604 Ic 6-8-N 6'7;04