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ELL DESTRUCTION PERM?-- <br /> PUBLIC WATER SYSTEM ❑Yea 0 ND <br /> t SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> 304 E WEBER AVE 3"FL-STo TON CA 95202 - (209)468.3420 <br /> NON-REFUNDABLE PERMIT CALL(209)953-7697 FOR INSPECTIONS EXPI <br /> SSUED <br /> JOB ADDRESS 2ai n.q / CITY/ZIP <br /> CROSS STREET <br /> APN --13�d'-�s PARCEL SIZE <br /> OWNER (J L�yAND USE APPLICATION# <br /> / PHONE <br /> OWNERADDRESS Vi CITY/STATEIZIP <br /> CONTRACTOR <br /> PHONE <br /> CONTRACTOR ADDREss <br /> / CITY/STATE/ZIP <br /> L9�C-57 WELL DRILLING LICENSE NU BER4�2 / EXPIRATION DACE S <br /> PERFORATION CONTRACTOR PHONE <br /> PERFORATION CONTRACTOR ADDRESS CITY/STATE/ZIP <br /> 13C-57 Well Drilling License Number <br /> Expiration Date <br /> ❑ Bureau of Alcohol,Tobacco and Firearms-Users of High ExplosivesLicense Number (�y <br /> Expiration Date V! <br /> 13CHP Hazardous Ma terial'Transportation for Explosives License Number <br /> Expiration Date <br /> O San Joaquin County Sherift=Coroner Explosives Application and Permit License Number ' <br /> Expiration Date <br /> ❑ California Occupational Safety Health-Blaster License Number <br /> Expiration bate <br /> REASON FOR DESTRUCTION ❑ Dry ❑ Replacement Weil ❑ Caved 1n ❑ Pit Well ` <br /> inactive p Test Hole <br /> Ei Detected!Suspected Well Water Contaminants) <br /> Adjacent property with contamination (Address) <br /> Known Soil/Water contaminants at adjacent property M <br /> t, <br /> EXISTING WELLCONSTRUCTIO DETAILS ❑ Open Bottom Gravel Pack ❑ Uncased ❑ .Other <br /> Well Lag copy attached ❑ Yes X. Grout Seal ❑ No ❑ Yes ft below ground surface(bgs) Hole Diameter _inches { <br /> Well Conductor CasingYes No . Depth of Conductor Casing ft bgs Diameter of Conductor Casing inches F <br /> Well Casing Diameter � CI inches Total Depth ft De th to Water g i <br /> p Depth of Casing ft bgs <br /> DESTRUCTION SPEOEICATION <br /> Sealing Material from 106 _ft bgs to ft bgs Filler Materiel from ft bgs to Jj�W —ft bgs <br /> Well casing to be perforated by one- f the fit win methods: from ft bgs to ft bgs <br /> ❑ Mills Knife Number of cuts every ft and/or <br /> ❑ Explosives ❑ Detonating cord ❑ with projectiles every It ❑ without projectile <br /> f ❑ Detonating cord and boosters ❑ with projectiles every ft ❑ without projectile <br /> 17 Other <br /> Sealln '"aterial ❑ Neat Cement(941b bag/5-6 gat water) 13 SandCement ,rack mix/7 gal water ❑ Bentonite Pellets <br /> Bentonite(201/6 s s) ❑ Manufacturer Spec%solids °/" Name �pecs on File ❑ Specs Submitted <br /> Placement Method ar P <br /> jmhped ❑ Free Fall ❑ Other <br /> Seal Completion %" Complete with Mushroom Cap ft bgs p Complete to Existing Surface Pad <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE INACCORDANCEWITH 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 <br /> WORKERS COMPENSATION LAWS. <br /> 1 24 H R ADVANCE NOTICE REQUIRED FOR SPECTIONS <br /> CONTRACTORS SIGNATURE TITLE DATE <br /> i <br /> i <br /> 0-7 <br /> nZ <br /> T-F F <br /> --4±:LEjjJ <br /> J <br /> =P-A-R-T-M-E N'=T—'U=S=E O N-1T-Y <br /> Application Accepted 13 Date <br /> 'Area <br /> f <br /> Destruction Inspection BY Date ./�� /,� Employee 1D# <br /> COMMENTS ' --- <br /> PE SC Received Che Amount Date Permit/' Invoice# Well!D# <br /> Codes t Info B Cash Remitted Service Request# <br /> b (21 SE-00q-71-�Lg <br /> EHD 43-02-008 - <br /> 1!21/2005 <br /> Well Destruction Permil <br />