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WELL DESTRUCTION PERMIT PUBLIC WATER SYSTEM ❑Yes J� SAN JOAOUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 East Hazelton Avenue-STOCKTON CA 95205 - (2099))468'-3420 NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED -r. JOB ADDRESS 212YL v CITY/ZIP — /� p 9 CROSS STREET��:2 ��/`t..� QPN / �— G�� PARCEL SIZE AND USE APPLICATION# OWNER 1'7J4 / J t.� �� /� PHONE /� J —;7 OWNER ADDRESS 2 `e; E t 'y—..r�� 77C— CITY/STATE{Z/IjP ) 2 �'zp�- r CONTRACTOR. �G "G��/LJJ- 7�L� /�� PHONE %� CONTRACTOR ADDRESS .li�C�� CITY/STATE/ZIP — C 25 Qlf C-57 WELL DRILLING LICENSE NUMyfR> �[�'J, � EXPIRATION DATE PERFORATION CONTRACTOR y — HONE PERFORATION CONTRACTOR ADDRESS 2 L7 _ CITY/STATE/ZIP ❑ C-57 Well Drilling License Number Expiration Date ❑ Bureau of Alcohol,Tobacco and Firearms-Users of High Explosives License Number Expiration Date ❑ CHP Hazardous Material Transportation for Explosives License Number Expiration Date ❑ San Joaquin County Sheriff-Coroner Explosives Application and Permit License Number Expiration Dat ❑ California Occupational Safety Health-Blaster License Number Expiration Dat REASON FOR DESTRUCTION ❑ Dry ❑ Replacement Well ❑ Caved In ❑ Pit Well �► Inactive ❑ �)rl;iole Detected/Suspected Well Water Contaminant(s) )W 1 9 Adjacent property with contamination (Address) JO I Known Soil/Water contaminants at adjacent property_ // CW/Rp �CO�� —-- -- T--' Affm EXISTING WELL CONSTRUCTION DETAILS ❑ Open Bottom ❑ Gravel Pack ❑ Uncased ❑ Other _NT Well Log copy attached ❑ Yes ❑ No Grout Seal ❑ No ❑ Yes If below ground surface(bgs) Hole Diameter _ inches Well Conductor Casing ❑ Ye5 ❑ No Depth of Conductor Casing ft bgs Diameter of Conductor Casing _ inches Well Casing Diameter __—inches Total Depth _ Pv It Depth to Water_ A __It Depth of Casing _ It bgs DESTRUCTION SPECIFICATION {� Sealing Material from It bgs to _ It bgs Filler Material1/4rBj m '2_ft hmo f/O/—ftIsf" Well casing to be perforated by one of the following methods: from ft bgs to _ It bgs ❑ Mills Knife ____ _Number of cuts every___------___ ft and/or____ Explosives ❑ Detonating cord ❑ with projectiles every It ❑ without projectile Detonating cord and boosters W with projectiles every --ID It ❑ without projectile ❑ Other__ Sealing Material Neat Cement(94 Ib bag/5-6 gal water) Sand Cement Wr sack mix17 gal water Bentonite Pellets Bentonite(20%solids) Manufacturer Spec%solids _% Name L; Specs onFileSpecs Submitted Placement Method Pumped Free Fall Other � &01 I_yr Seal Completion Complete with Mushroom Cap4 .-_.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 I AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION LAWS. y , MI HVANCE NOTICE REQUIRED FOR/INSPECTIONS CONTRACTORS SIGNATURE �� C TITLE f�' �'� DATE _ -._ -- - C E � E E E ` D E P A R T M E N T U S E 0 NA Y Application Accepted By Date /vl ,,,�)hq Area Destruction Inspection By Date ` Employee ID# COMMENTS PE SC Received he Amount Date Permit/ Invoice# Well ID# Codes Info Cash Remitted_ Service Request# EFID 43-08 WELL DESTRUCTION PERMIT 4/30/12