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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 a-l0 Pl ( JOB ADDRESS �1tn -- CITY/ZIP �� 3 CROSS STREET 'X AP PARCEL SIZE LND USE APPLICATION# 7z-- 7 OWNER PHONE :y / /L OWNER ADDRESS �J1'{/ CITY/STATE IP "A5 ✓ CONTRACTOR I L- S PHONE / //��+� y CONTRACTOR ADDRESS / �� 0 S �� gypp" CITY/STATE/ZIP �� $S C-57 WELL DRILLING LICENSE NUMBER O/`Z> EXPIRATION DATE 7-0 /,/l PERFORATION CONTRACTOR 04 'I 4, Y PHONE / Z�7 PERFORATION CONTRACTOR ADDRESS � 7_ � / �5ew7/4-'C- CITY/STATE2IP oo C-57 Well Drilling License Number OC o Expiration Date Bureau of Alcohol,Tobacco and Firearms-Users of High Explosives License Number Expiration Date ur CHP Hazardous Material Transportation for Explosives License Number Expiration Date ❑ San Joaquin County Sheriff-Coroner Explosives Application and Permit License Number Expiration Date 1d., California Occupational JW&Health-Blaster License Number Expl tion Date REASON FOR DESTRUCTION ❑ Replacement Well p Caved In ❑ Pit Well active ❑ Test Hole Detected/Suspected Well Wa r Contaminants) 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 ❑ es ❑ No Depth of Cod for Casing ft b s Diameter of Conductor Casing inches Well Casing Diameter__inches Total Deptfy( ft Depth to Water_ft Depth of Casing ft bgs DESTRUCTION SPECIFICATION Sealing Material from ft bgs to Z� ft 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 06 Detonating cord ❑ with projectiles every ft ❑ without projectile 19 Detonating cord and boosters ❑ with projectiles every ft ❑ without projectile ❑ Other Sealing Material Neat Cement(94 lb bag/5-6 gal water) Sand Cement sack mix'7 gal water Bentonite Pellets Bentonite(2'0%solids) Manufacturer Spec%solids % Name Specs on File Specs Submitted Placement Method Pumped Freef-all— 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. MINIM 4 HOUR AD NCE NOTICE REQUIRED FO",SPECTIONS CONTRACTORS SIGNATURE TITLE DATE 7� __ _._...._...._..... .. ... .. .. ._ .... ._ ..... �..._._.. ! 4 �._...__. ; __, f� H _.. .. . __ _. ! ..... ..............................._.._.............._._..................__... . _ __ __................._...........__............... ...... _.....__. _._.. .._ ..... ......_..._._._ __...__.._..__ .._._.__._t_.._ .... _.._ .. .. _ .. ...... ....... _ ! i ( I I I �l I I .._...........__!_.�_ ___ .._.__, ___ ___._.. ...__ ... ..__._1..._.._. _ ._ ..__ _...... ... __ i c EPARTMENT USE ONLY Application Accepted By Date Area Destruction Inspection By, [. Date Employee IDI/ COMMENTSLl/'QU PE SC Receivedhk#/ Amount Permit/ Codes Info ecDate Remitted Service Repuest# Invoice# Well ID# -1SS� t I EHD 43-08 WELL DESTRUCTION PERMIT 4/30/12