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SCANNT'D WELL DESTRUCTION PERMIT PUBLIC WATER SYSTEM ❑Yes ❑No <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 East Hazelton Avenue-STOCKTON CA 95205 - (209)468-3420 <br /> NON-REFUNDA E PERMIT, CALL(2p9)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS Q / CITY/ZI p <br /> CROSS STR T APNI !! (/]C�(�_ "IL <br /> PARCEL SIE AND USE APPL ION# <br /> z <br /> OWNER PHONE Ri <br /> OWNER ADDRESS CITY/STATE/ZIP r <br /> CONTRACTORA&M PHONE <br /> CONTRACTOR ADDRESSCAX CITY/STATE/ IP v <br /> ❑ C-57 WELL DRILLING LICENSE NUMBER EXPIRATION DATE <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 <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 ❑ Yes ❑ No Grout Seal ❑ No ❑ Yes _ _ _ft 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 Diameterinches Total Depth ft Depth to Water__- It Depth of Casing - It bgs <br /> DESTRUCTION SPECIFICATION <br /> Sealing Material from ft bgs to _ ft bgs Filler Material_ _ from ft bgs to ft bgs <br /> Well casing to be perforated by one of the following methods: _ _ from _ __ft bgs to _ ft bgs <br /> ❑ Mills Knife Number of cuts every ft and/or <br /> ❑ Explosives ❑ Detonating cord ❑ with projectiles every ft ❑ without projectile <br /> ❑ Detonating cord and boosters ❑ with projectiles every ft ❑ without projectile <br /> ❑ Other <br /> Sealing Material Neat Cement(94 Ib bag/5-6 gal water) Sand Cement sack mix/7 gal water Bentonite Pellets <br /> Bentonite(20%solids) Manufacturer Spec%solids % Narne _ Specs on File n Specs Submitted <br /> Placement Method Pumped ❑ Free Fall (- Other lr�)o <br /> Seal Completion MComplete 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 /> 4 H V�ANCE NOTICE REQUIRED FOR INSPECTIONS <br /> CONTRACTORS SIGNATURE TITLE DATE z� <br /> + i I f9 1 _ t _ <br /> _ v <br /> ....... <br /> M\ <br /> .......... .__.. ............ ........ _. - .. <br /> �. ,._. � _ ............ <br /> PAYMENT ' <br /> RECEIVE® <br /> �t <br /> W_ JUL 2 4 2018 <br /> SAN JOAQUIN COUNTY ___. .._...._....__.... . <br /> ENVIRONMENTAL <br /> HEALTH <br /> DEPARTMENT .�' __�_ _..�__ � __ �.__ .,.-_.. \ � ._�,.,,... �.w-_L___. _. _. <br /> _i <br /> 44-4 <br /> 44 <br /> ............. <br /> DEPARTMENT USE ON LrY <br /> Application Accepted By Date Area <br /> Destruction Inspection By/ Date Employee I <br /> COMMENTS <br /> f-\J - -3 ' o <br /> _a ic�vt jti' �� . ,-: l' <br /> 71 <br /> PE SC Received Ch Amount Date PermiU Invoice# Well ID# <br /> Codes Info By Cash Remitted Service Request# <br /> EHD 43-08 WELL DESTRUCTION PERMIT <br /> 4/30/12 <br />