SU0006589 - Laserfiche WebLink

Home Browse Search

1 WELL DESTRUCTION PER�UT _ PUBLIC WATER SYSTEM ❑Yes Y SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE 3"°FL-STOCKTON CA 95202 - {209)k' NON-REFUNDABLE PERMIT CALL(209)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATTjE�Isf JOB ADDRESS SLA+'1 CITYIZIP CYJ�J y, CROSS STREET__ WQuAPN 143t 2 O PARCEL SIZE L `. OWNER O aj1-1) PHONE OWNER ADDRESS � S CITYISTATE/Z��IrrP�� / CONTRACTOR Q tJ� PHONE V t �/ I I CON,,,'i{{{'RACTORADDRESS 00 r-- e V f CITY/STATE/ZIP �p C-57 WELL DRILLING LICENSE NUMBER �~� � r� EXPIRATION DATE 1' tl PERFORATION CONTRACTOR PHONE PERFORATION CONTRACTOR ADDRESS CITY/STATE/ZIP ❑ C-57 Well Drilling License Number Expiration Date i ❑ Bureau of Alcohol,Tobacco and Firearms-Users of High Explosives License Number Expiration Date ❑ CHF 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 Contaminants) Adjacent property with contamination (Address) j Known Soil/Water contaminants at adjacent property f EXISTING WELL CONSTRUCTION DETAILS ❑ Open'Bottom Q Gravel Pack Uncased ❑ Other tt Well Log copy attached ❑ Yes ❑ No Grout Seal ❑ No ❑ Yes ft below gmqund surface(bgs) Hole Diameter O i! inches 1 Well Conductor Casing ❑ Yes ❑"No Depth of Cond ctor Casing ft bgs Diameter of Conductor Casing inches Well Casing Diameter inches Total Depth et7 ft Depth to Water�v:15 ft Depth of Casing ft bgs DESTRUCTION SPECIFICATION Sealing Material from ft bgs to ft bgs Filler Material from ft bgs to ft bgs II Well casing to be perforated by one of the following methods: from ft bgs to ft bgs Cl Mills Knife Number of cuts every ft and/or ❑ Explosives ❑ Detonating cord ❑ with projectiles every ft ❑ without projectile ❑ Detonating cord and boosters ❑ with projectiles every ft 11without projectile ❑ Other Sealing Material CJ Neat Cement(941h'bag/5-6 gal water) ❑ Sand Cement sack mix/7 gal water Bentonite Pellets 13 Bentonite(20%solids) ❑ Manufacturer Spec%solids-% Name ❑ Specs on File ❑ "Specs Submitted Placement Method ❑ Pumped ❑ Free Fall ❑ Other Seal Completion Complete with Mushroom Cap ft bgs ❑ Complete to Existing Surface Pad I HEREBY CERTIFY THAT I 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 LA S. 1N 24 HIXADVANCE NOTICE REQUIRED FOR INSPECTIONS CONTRACTORS SIGNATURE TITLE ..DATE 2 C� _ ' ' " - ---�- - 44 _4� - - - - F.-_ F ;J_ _ t 1 jai- +ar DEPA )R M E N T USE ONLY ) �� Application Accepted Date Area Destruction Inspection By Date Employee ID# COMMENTS 4�f b - P- PE SC Received kCAeclt# Amount Date Permit/ Invoice# Well ID# Codes Info B Cash Remitted Service Request# 51 END 43-02-009 1/;7/2005 Wall rII a.