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WELL DESTRUCTION PERMIT <br /> PUBLIC WATER SYSTEM ❑Yes No <br /> SAN JOAQUIN COUNTY EwymmuENTAL HEALTH DEPARTMENT 600 E MAN STREET-SToCKToN CA 9=2-(209)466-3420 <br /> NON-REFUNDABLE PERMIT-- CALL(2091953-7697 Fog INSPECTION$ EXPIRES 1 YEAR FROM DATE ISSUED <br /> Jos Aeewcce 9S�6y t._J t4uj aZ -rrrdbr 4-010/ <br /> CROSS STREET !i-w— I/�2 , APN OSS- /(vo PARCEL StzE-9 a USE APPUCwnoN p <br /> OWNER D�JOR I LllPS PHONE C <br /> OWNER ADDRESS CJTy/STATEMP <br /> CONTRACTOR_1 C e-1 t1- t'.-'56� f.��-I I Fj t P� —.� PHONE ,/�1 <br /> CONTRACTOR ADDREr ,e-A. �Jo 2S Z- rr <br /> CnY/STATEIZiP'Lo-a,� . L fs-2 Y1 <br /> ❑ C-S7 WELL DRILLNG LICENSE NUMBER '6 W ars I Z EXPIRATION DATE Z-o// ' <br /> PERFORATION CONTRACTOR PHONE <br /> PERFORATION CONTRACTOR ADDRES5 CMY/STATFJZIP <br /> ❑ C-57 Well Drilling License Number <br /> Expiration Date <br /> ❑ Bureau of Aloohol,Tobacco and Firearms-Users of High Explosives License Number <br /> Expiration Date <br /> ❑ CHP Hazardous Material Transportation for Explosives License Number Expiration Date <br /> ❑ San Joaquin County Sheriff-Coroner Explosives Applicatlon and Pemvt License Number Expiration Date <br /> ❑ California Occupational Safety Health-Biaster. License Number Expiation Data <br /> REASON FOR DEZMCTK7N ❑ Dry ❑ Replacement Well ❑ Caved In ❑ Pit Well ❑ inactive ❑ Test Hole f <br /> Detected/Suspected Well Water Contaminants) <br /> Adjacent property with contamination(Address) <br /> Known Soil/Water contaminants at adjacent p operty <br /> EffiaT1NG WELL CONSTRUCTION DETAILS ❑ Open Bottom ❑ Gravel Pack ❑ Uncased ❑ Other_ (w <br /> Well Log copy attached ❑ Yes ❑ No Grout Seal ❑ No ❑ Yes ft below ground surface(bgs) Hole Diameter incites <br /> Well Conductor Casing❑ Yes ❑ No Depth of Conductor Casing it bgs Diameter of Conductor Casing__inches 0 <br /> Well Casing Diameter 61 inches Total Depth_TV It Depth to Water Zb ft Depth of Casing It bgs <br /> DuTRUCTION SPecw"TION -� <br /> Sealing Material from__TV it bgs to_-�_it bgs Filter Material .g�,<s n 1e�i from____it bgs to fl legs <br /> Well casing to be perforated by gree of the following methods: from It bgs to ft bgs `x <br /> ❑ Mills Knife Number of cuts every R andlor <br /> ❑ Explosives❑ De+mat ng cord ❑ w 1i projectiles every it ❑ without projectile <br /> ❑ Detonating cord and boDa ars ❑ with projectiles everyIt ❑ without projectile <br /> Q Other II <br /> Sealing Material ❑ Neat Cement(941b beg/5-6 gal water)r, Sand Cement sack mix f gal water y5[ Bentonite Pellets '�► <br /> Bentonite(20%sWids) 11Manufacturer Spec 90 solids_!o Name ❑ Specs on Fite 'l Specs Submitted I�r\ <br /> Placement Method 7, Pumped 0 Free Fall ❑ Other <br /> ' Seal Completion 2 Complete with Mushroom Cap S ft bgs U Complete to Existing Surface Pad <br /> 1 HEREBY CERTIFY THAT 1 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 1 AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> MINNUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS r <br /> CONTRACTORS SIGNATURE /eyyA .Tmt d�77�+L 0A-m E:,7-90-1e <br /> I <br /> tt <br /> i' <br /> i PAY. <br /> } <br /> r <br /> Application Accepted By - - Date S�-7 10i Area <br /> Destruction inspection Br 0 - Employee 1 _, T <br /> I <br /> COMMEi1dT •✓r / <br /> . 26 <br /> PE Received CharJd/ Amount Date Permit/ In� y t# Well IDN <br /> Codes Info B Remittal Ssrvice R oast# <br /> EHD 43-08 WELL DESTRUCTION PERMIT <br /> fasro7 <br />