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WELL STRLICTION PERMIT , /00, <br /> i Li L0.1 ❑Yea ❑No <br /> SAN JOAGUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 600 E MAIN ST*I, <br /> N 2 -(209)466-3420 <br /> NON-REFUNDABLE PERMIT ALL(209)953- 97 R INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS C f CRY(ZIP �� rt <br /> CROSS STREET C APNLQZ - ,OA/U -47� PARCEL SQE; 4AND USE APPLICATION M o <br /> ` OWNER � a✓7/ PHONE <br /> OWNER ADORESS YY• CItt/STATHZIP f-/ / <br /> CONTRACTOR 1 PHONE <br /> CONTRACTOR ADDRESS 9rr'l CRYISTATERN n <br /> /J,�f. C-57 WELL DRILLING LICENSENUMBER 3 '770 Ufa EXPIRATION DATE A <br /> PERF00.ATNIN CONTRACTOR PHONE <br /> PERFORATION CONTRACTOR ADDRESS CITYISTATE(ZIP <br /> ❑ C-57 Well Drilling License Number Expiration Data d <br /> ❑ Bureau of Alcohol,Tobacco and Firearms-Users of High Explosives License Number Expiration Date <br /> ❑ CHP Hazardous Malarial 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 Data <br /> REASON FOR DESTRUCTION ❑ Dry ❑ ReplaC ant Well ❑ Caved In ❑ Pit Well Xnactive ❑ Test HOle <br /> Detected/Suspected Well Water Comaminarrl <br /> Adjacent property with contamination(Address) <br /> Known Soil/Water contaminants at adjacent property <br /> EXISTING WELL CONSTRUCTION DETAILS ❑ Open BOftm ❑ Gravel Pack ❑ Uncased ❑ Other <br /> Well Lag copy attached ❑ Yes 11No Grout Seal ❑ No ❑ Yes R below ground surface(b95) Hola Diameter intoes <br /> _ Well Conductor Casing Yes ❑ No Depth of Conductor Casing It bgs Diameter of Conductor Casing inches <br /> Well Casing Diameter 11 inches Total Depth ?E ft Depth to WaterDepth of Casing ft bgs <br /> DESTRUCTION SPECIFICATION <br /> Sealing Material from-_-ilbgsW "�ftbgs Fillar Material Rom ftbgstG Rbgs <br /> Well casing to be perforate tl by one arms following methods: Rom R bgs to R bgs <br /> ❑ Mills Knife Number of cuts every Randfor <br /> ❑ Explosives Detonatingoord ❑ with projectiles everyR ❑ without projectile <br /> ❑ Detonating cord and boosters ❑ withproiectlles everyft ❑ vAthoul projectile <br /> ❑ Other <br /> Sealing Material)( Neat Cement(94 lb bagl"gal wafer)❑ Sand Cament sack mix 7 gal water Bentonite Pellets <br /> ❑ Bentonite(20%solids) ❑ Manufacturer Spec%solids % Name ❑ Specs on File ❑ Specs Submitted <br /> Placement Method ❑ Pumped �Z Free Fall ❑ Other <br /> Seal Complegon,A Complete with Mushroom Cap 3 �?) R bgs X 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 /> 24 HOUR CE NOTICE REQUIREFOR INSPECTIONS <br /> CONTRACTORS SIGNATURE TITLE TR,� DATE <br /> I <br /> t � <br /> F, (Ori � e 6i 7.Ot7A <br /> bT <br /> JOAONMENrAL <br /> // H IROME <br /> DEPAITTMENT <br /> DEP +tJ NT USE ONL ra '[ <br /> Destruction <br /> Accepted By fill Date Area <br /> Destruction InspeNon Date � 7'/rX- Employee IDM <br /> COMMENTS plc � ✓�/3 m- ty� 3� '� —r �°„ <br /> PE SCReceived Check#P Amount Data Permit/ Invoice# Well IDM <br /> Codes Info B emitted Service Re uest0 <br /> �'l D3o ISn.P" b D <br /> EHD 3-09 WELL DESTRUCTION PERMIT <br /> rm T <br />