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WELL DESTRUCTION PERMIT <br /> PUBLIC WATER SWIft o <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE 3"n FL-STOCKTON CA 95202 -(209)468-3420 <br /> NON-REFUNDABLE P RMI ALL(209)953-7697 FOR INSPECTIONS EXP ES 1 YEAR FROM DATE ISSUED <br /> y <br /> JOBADDRESS CITY/ZIP f <br /> CROSS STREET ✓t ^ APN 310 3 0 0 PARCEL SIZE AND USE APPLICATION# _ <br /> OWNER­, 1 ,i d-� PHONE <br /> OWNER ADDRESS CITY/STATE/ZIP <br /> CONTRACTOR C-- PHONE <br /> CONTRACTOR ADDRESS c CITY/STATE/ZIP <br /> 11J C-57 WELL DRILLING LICENSE NUMBER 3 :2 :2,9 s4U EXPIRATION DATE <br /> PERFORATION CONTRACTOR PHONE <br /> PERFORATION CONTRACTOR ADDRESS CITY/STATE/ZIP <br /> ❑ C-57 Well Drilling License Number Expiration Date <br /> ❑ Bureau of Alcohol,Tobacco and Firearms-Users of High Explosives License Number Expiration Date <br /> ❑ CHP Hazardous Material 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 Date <br /> REASON FOR DESTRUCTION Dry ❑ Replacement Well ❑ Caved In ❑ Pit Well ❑ Inactive ❑ Test Hole <br /> Detected/Suspected Well Water Contaminant(s) <br /> Adjacent property with contamination (Address) <br /> Known Soil/Water contaminants at adjacent property <br /> EXISTING WELL CONSTRUCTION DETAILS X Open Bottom ❑ Gravel Pack ❑ Uncased ❑ Other <br /> Well Log copy attached ❑ Yes 14 No Grout Seal)4 No ❑ Yes R below ground surface(bgs) Hole Diameter inches (� <br /> Well Conductor Casing ❑ Yes )K No Depth of Conductor Casing ft bgs Diameter of Conductor Casing inches <br /> Well Casing Diameter inches Total Depth ft Depth to Water ft Depth of Casing!_ft bgs (i,3 <br /> DESTRUCTION SPECIFICATION <br /> Sealing Material from 01,0 ft bgs to ft bgs Filler Material from ft bgs to ft bgs <br /> Well casing to be perforated by one of the followlne methods., from ft bgs to It bgs <br /> ❑ Mills Knife Number of cuts every ft and/or <br /> ❑ Explosives ❑ Detonating cord ❑ with projectiles everyft ❑ without projectile <br /> ❑ Detonating cord and boosters ❑ with projectiles every R ❑ without projectile t^ <br /> ❑ Other <br /> Sealing Material ❑ Neat Cement(94/h hag/5-6 gal water) X Sand Cement /7 sack mix/7 gal water ❑ Bentonite Pellets <br /> ❑ Bentonite(20%solids) ❑ Manufacturer Spec%solids % Name ❑ Specs on File ❑ Specs Submitted ` <br /> Placement Method❑ PumpedZ Free Fall 13Other <br /> Seal Completion ❑ Complete with Mushroom Cap /all 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. 1 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 /> �NIM �HQU�ANCE NOTICE REQUIRED FOR <br /> INSPECTIONS <br /> CONTRACTORS SIGNATURE TITLE ( Cid DATE 5 <br /> AP«'� PAYMEI JT <br /> RECEIV D <br /> MAY 2 4 2107 <br /> SAN JOAQUIN C UNTY <br /> ENVIRONMEN-AL <br /> v HEALTH DE ART ENr <br /> 5'e`' <br /> DEPARTMENT USE ONLY 2(/ <br /> Application AceBj,' / DateS250 Area <br /> doDestruction InsP� DaEmployee <br /> ee ID# <br /> og"j(-, <br /> COMMENTS <br /> PE SC Received heck#/ Amount Date PermiU I"voice# Well IDN <br /> Codes Info B Remitted Service Re nest# <br /> '13:7- !(-t �(�lb� 5W J` 1 <br /> EHD 41-02-00" <br /> 177?005 u'dl D­­n P­,, <br />