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4� 'ELL DESTRUCTION PERM- PUBLIC WATER SYSTEM ❑Yes %No SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE 34"FLOOR-STOCKTON CA 95202 - (209)468-3420 NON-REFUNDA L PERMIT CAIL 09)953-7697 FOR INSPECTIONS EXPIRES I YEAR FROM DATE ISSUED Ln JOB ADDRESS IVV A/'/v- 21 q east ' *y/ZIP OWNER PHONE 92-2 v O OWNER ADDRESS CITY/STATE/ZIP CONTRACTOR A PHONE L, CONTRACTOR ADDRESS 2-0 92VC: / _ JUAIJ CITY/STATE/ZIP I J toNTC-57 WELL DRILLING LICENSE NUMBER EXPIRATION DATE PERFORATION CONTRACTOR PHONE PERFORATION CONTRACTOR ADDRESS CITY/STATE/ZIP B--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 ❑ 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 . liv Well Conductor Casing ❑ Yes ❑ No Depth of Conductor Casing ft bgs meter of Conductor Casing inches fQ Well Casing Diameter inches Total Depth ft Depth to Water ft Depth of Casing ft bgs W DESTRUCTION SPECIFICATIO Sealing Material from I ft bgs to — 3 ft bgs Filler Material Ci 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 ❑ Detonating cord: ❑ with projectiles every ft ❑ without projectile ❑ Detonating cord and boosters: ❑ with projectiles ev ft ❑ without projectile ❑ Other Sealing Material Neat C ent(94/b bag/5-6 gal water) San ement ZA ack mix/7 gal water ❑ Bentonite Pellets C ❑ Bentonite(20° soli ❑ Manufacturer Spec%solids me ❑ Specs on File ❑ Specs Submitted Placement Method Pumped ❑ Free Fall Other Seal Completion: ❑ Complete with Mushroom Cap ft bgs ❑ Complete to Existing Surface Pad 1 HEREBY CERTIFY THAT 1 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 1 AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION LAWS. MINI UM 2 VANC NOTICE REQUIRED FOR IN PECTIONS CONTRACTORS SIGNATURE:" 'n .,IyTITLE: 1JATE.:Z z�d j 1 _.r-- _a • 1 Itul � - - , g-2 -- . G �- 1 --44 - -77 E v V4 PA,R.`.MENT i DEPARTMENT USE ONLY Application Accepted By - Date Q �7 �� Area (,, --f Destruction Inspection By Date J Employee ID# l c{Sb COMMENTS Z v PE SC Received Check#/ Amount Date Permit/ Invoice# Well ID# Codes Info B as Remitted Service Request# 4.4-73 it,,/ '?36:7 (Sc .cam} a D5!d 327 EHD 43.02-009 6/7;04 Well Destruction Permit Addendum 4604 Ic 6-9-04