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WELL DESTRUCTION PERMIT PUBLIC WATER SYSTEM ❑Yes ❑No SAN JOAOUIN 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 JOBADDRESS � / �J�L�?/��Q /�y� ^� CITY/ZIP CROSS STREET APNPARCEL SIZE LAND USE APPLICATION # OWNER -/ 4 II tG PHONE c:m!Z 66--1- 7_Zg5' OWNER ADDRESS 7Co(p L� E /AyL�r /J�clll �!/ _ CITY/STATE/ZIP "A -,7,5 ,Z 2 CONTRACTORe3," DWI/442 Zoe__ PHONE 21!21 -7 7 Z Z72'- CONTRACTOR ADDRESSCITY/STATE/ZIP 4:4& O O�,nI,S L%� ZS—Z 3"Z A C-57 WELL DRILLING LICENSE NUMBER 16117e:7,6 EXPIRATION DATE `�3l Zo20 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 ❑ 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 9 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 ft Depth to WatCS- ft Depth of Casing ft bgs DESTRUCTION SPECIFICATION I g y g i�from ft bgs to ft bgs Sealing Material from ft bgs to ft b s Filler Material_ °—�.■�■ Well casing to be perforate by one of the following methods: from ft bgs to It bgs ❑ Mills Knife Number of cuts every It and/or ❑ Explosives ❑ Detonating cord ❑ with projectiles every It ❑ without projectile ❑ Detonating cord and boosters ❑ with projectiles every ft ❑ without projectile ❑ Other Sealing Material Neat Cement(94 Ib bag/5-6 gal water) Sand Cement 3 sack mix17 gal water Bentonite Pellets Bentonite(20%solids) Manufacturer Spec%solids % Name Specs on File Specs Submitted Placement Method Pumped Free F / 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. 4/8 MINIMUM OUR ADV NOTICE REQUIRED FOR INSPECTIONS CONTRACTORS SIGNATURE TITLE �� 5�-��1/'s��DATE _._..........__........ .------ ...._-... - _.... .. .................... ............................................... I f i ' f .._...._.-....._____ ___ ___ __.....-....._._i...._._....._..__..._._..___..__..__._..__...__....... .__ _.. .. _..._._...._ __ ._ ... ... .. .. _.._ -JPAYME _ RECrZIVE foft, 0.3 _ 0l -SAN J0A6UIN C U TY .._..._....._......__._... _........_._......... ENVIRONMENTAL -- -HEALTH DEPARTMENT A r DEPARTMENT USE ON Y Application Accepted By Date Z Area 4, ` Destruction Inspectio y Date Employee I #1 COMMENTS V� L f � PE SC Received Check#/ Amount Permit/ Codes Info B Cash Remitted Date Service Request# Invoice# Well ID# 431 14 1 KNOO EHD 43-08 WELL DESTRUCTION PERMIT 4/30/12