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WELL DESTRUCTION PERMIT ; <br /> \ U <br /> )-..-AC WATER SYSTEM-. es <br /> SAN JOAQUIN COUNry I:NVIRONMENTALHEALTH DEPARTMENT 304E WEBER AVE$u°FL-STOCKTON CA 95202 - <br /> 0 <br /> NON-REFUNDABLE PERMIT CALL(209)953-7697 FOR INCPECTION:s EXPI ES I YEAR FROM DAT ISSUED <br /> �y _m <br /> JOB ADDREss Y C[TYIZFP L <br /> CROSS ST APN — PARCELAZE LAND USE APPL CATION IF C <br /> tj -fiOWNER 1! PHONE <br /> OWNER ADDRESS f Cr V)STATVZIP rn <br /> CONTRACTOR PHON � <br /> CONT CrORADDRE L• CITYISTATFJZIP �j Q <br /> C-$7 WELL DRILLING LICLNSE NUMBER E%PIRATION DA U <br /> PERFORATION CONTRACTOR PHONE <br /> PERFORATION CONTRACTOR ADDRESS CITYISTATEIZIP <br /> I <br /> ❑ C-57 Well Drilling License Number Expiration Date <br /> ❑ Bureau of Alcohol.Tobacco and Fircamns-Users of High Explosives License Number Expiration Date L <br /> ❑ CHP Hazardous Material Transportation for Explosives License Number Expiration Date <br /> j ❑ San Joaquin County Sheriff-Coroner Explosives Application and Permit License Number Expiration Date ' <br /> ❑ California Occupational Safety Health-Blaster License Number Expiration hate <br /> REASON FOR DESTRUCI'lON ❑ Dry 0 Repla emtm Wcll ❑ Caved In ❑ Pit Well ❑ Inactive ❑ Tess Hole <br /> I <br /> Detected I Suspected Well WaterConlaminant(s) , <br /> Adjacent property trithcontamination(Address) <br /> Known Soil!Water contaminants at adjacent property <br /> i <br /> EXInING WELL CONsrnwrION D ❑ open Bottom Er Gravel Pack ❑ Uncascd ❑ Other <br /> Well Log copy attached ❑ Yes N Grout Seal ❑ No ❑ Yes ft below ground surface(bgs) Hole Diameter inches ; <br /> Well Conductor Casing 13 Yes "0 Depth Of Conductor Casing fl bgs Diameter Of Conductor Caslne inches t <br /> Well Casing Diameter inches Total Depth, b Depth to Water__,-_ft Depth of Casing fl bgs r <br /> DEST1RtJC1IQN SPECIF[ ATION <br /> Sealing Material from Jf}11i7&4 ft bgs to.771!�?,R bgs Filler Material from fl bgs to R bgs <br /> Well call ng to be perforated by one of the foiiowin methods: from ft bgs to It bgs <br /> ❑ Mills Knife Number ofcuts every R and I or <br /> ❑ Explosives ❑ Detonating cord ❑ with projectiles every ft ❑ w thout projectile <br /> ❑ Detonating cord and boosters ❑ with projectiles every ft ❑ without projectile <br /> ❑ Other <br /> Sealing Material ❑ Neat Cement A hog 15-6gaJ wmer) ❑ Sand Cement sack mix 17 gal water ❑ Bentonite Pellets <br /> "ntonite(20% t) Manufacturer Spec%solids % Name�,���G�"� U-�cs on File ❑ Specs Submitted <br /> Placement Methodff,Pupiped ❑ Free Fall ❑ Other <br /> Seal Completion EK'Complve with Mushroom Cap R bgs ❑ 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 I AM IN COMPLIANCE WITH ALL j <br /> WORKERS COMPENSATION LAWS. I <br /> M) OU DVANCE NOTICE REQUIRED FOR[NSPECTIONJI <br /> CONTRACTORS SIGNATURE TI r A1� <br /> + )f[f _ _ j <br /> - +�T��3 Z �� -cITI.C�dL�✓.�,.rY_ - +_� _T....�} r <br /> r.— _ I f F <br /> .I--E—rMAS <br /> -}- -1---'. •-- --�..�.-- ....t_...t. y_._ .Qf'�'f'v• 1`E�D. _ <br /> .._...,r._. *... 4..A -{-.i. —i —._I_i _�iWF1r=rw..- f <br /> t 11TiT`( <br /> q. <br /> t <br /> i y MEW <br /> jT <br /> i <br /> - 5 <br /> D �_R ENT U1.;SF ON Y <br /> Application AcceptedBy Date Area <br /> Destruction Irepectiun B - Date Employee IDN <br /> COMMENTS Zee 'YS _ - <br /> /Q.�ct�/�L—'-/yl/ l1f1�f�l <br /> PE SC Received eckW Amount Date Permit! Invoice N Well iDN <br /> Codes Info B Rro <br /> s euted Service R uest g <br /> ✓t� 7 <br /> EHD i3-0].OaN wea Dorm ec-Pmnn <br /> Imnacs <br />