WP0039778 - Laserfiche WebLink

Home Browse Search

WELL DESTRUCTION PERMIT PUBLIC WATER SYSTEM ❑Yes ❑No SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 East Hazelton Avenue-STOCKTON CA 95205 - (209)468-3420 NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS CITY/ZIP !F S E3 7 CROSS STREET APN Z- D' U PARCEL SIZE LAND USE APPLICATION# v ' /M Z� m OWNER �� rum S J PHONE IV 7Z p OWNER ADDRESS CITY/STATE/ZIP / CONTRACTOR / 2 L--, PHONE -V �i J CONTRACTOR ADDRESS CITY/STATE21P �Q5 C-57 WELL DRILLING LICENSE NUMBER O� EXPIRATION DATE -V/I/ V//I/ PERF/ORATION CONTRACTOR :6 O / 4 (Jjt J�ONE PERFORATION CONTRACTOR ADDRESS / [7 CITY/STATE/ZIP— ® _ 49 C-57 Well Drilling License Number Expiration DateJ� Bureau of Alcohol,Tobacco and Firearms-Users of High Explosives License Number — Expiration Date 1� 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 Sa et Health-Blaster License Number E iration Date RE SON FOR DESTRUCTION r ❑ Replacement Well ❑ Caved In ❑ Pit Well 64y Inactive ❑ Test Hole Detected/Suspected Well W aminant(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 ❑ ❑ No Depth of Conductor Casing--ft bgs Diameter of Conductor Casing inches Well Casing Diameter inches Total Depth�—ft Depth to Water It Depth of Casing_2 2— '_ft bgs DESTRUCTION SPECIFICATION Sealing Material from _ > ft bgs to X2--ft bgs Filler Material ! i 3 60 " _from - ft bgs to //2— 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 It and/or ❑ Explosives ❑ Detonating cord ❑ with projectiles every ft ❑ without projectile Detonating cord and boosters ❑ with projectiles every ft ❑ without projectile ❑ Other Sealing MaterialNeat Cement(94 Ib bag/5-6 gal water) Sand Cement sack mixll gal water Bentonite Pellets Bentonite(O—Z.solids) Manufacturer Spec%solids % Name Specs on File Specs Submitted Placement Method Y Pumped Free Fall Other Seal Completion Complete with Mushroom Cap ft bgs Complete to Existing Surface Pad I HEREBY CERTIFY THAT I 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. LID 7 8 MINIM lM 24�H0UR DVANCE NOTICE REQUIRED FOR I SPECTIONS L CONTRACTORS SIGNATURE TITLE DATE i ............�t 4-fl- I i i ! __.. .._. .............__..-......_.................._._....._... _..._ ._..._._._._ ... _._.........._......_................_......._.. .. _._ __ _. _._ .. _.._ ... .. ..._ .- .. _._ ... .. C D... ... i ......._. ...._...._ ..__._...__......._.... .._._._. ... ... ... _. .. __.. _ _ .._ M.J_, .w III __1 _ _. _.... _ ENVtRONM .NTL _ _ ..___,_. . _ _. -_.._ �ALTM DEPA T EN PARTM ENT USE ON Application Accepted By Date_ Area Destruction Inspection By Date Employee IDS COMMENTS PE SC ReceivedChec Amount Permit/ Codes Info Bv Cash Remitted Date Service Request# Invoice# Well ID# EHD 43-08 WELL DESTRUCTION PERMIT 4/30/12