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WELL DESTRUCTION PERMIT PUBLIC WATER SYSTEM ❑Yes ❑No SAN JOAOUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 East Hazelton Avenue-STOCKTON CA 95205 - (209)468-3420 NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED \^_ r JOB ADDRESS 8"t 1 'r YA��N 1 L CITY/ZIP Cae,A - n Y CROSS STREET ria'm6f- APN 9,Z7-V06 —led PARCEL SIZE/. ND USE APPLICATION# OWNER B1cA-'100trC..- c_ �^IAEA�n PHONE 9�C»�qr66 OWNER ADDRESS � G, 3 CITY/STATE/ZIP CONTRACTOR (y adt < f�' ' ` PHONE NTA t' C RACTOR ADDRESS t (((N 1 A l h e rS I CITY/STATE/ZIP C-57 WELL DRILLING LICENSE NUMBER EXPIRATION DATE PERFORATION CONTRACTOR PHONE PERFORATION CONTRACTOR ADDRESS CITY/STATE/ZIP v y� c ❑ C-57 Well Drilling License Number Expiration e�l ❑ Bureau of Alcohol,Tobacco and Firearms-Users of High Explosives License Number ExpiragornS) ❑ CHP Hazardous Material Transportation for Explosives License Number Expiration D e3 m ❑ San Joaquin County Sheriff-Coroner Explosives Application and Permit License Number � DIV — ❑ California Occupational Safety Health-Blaster License Number X1'0 -""nPy REASON FOR DESTRUCTION Dry Replacement Well ❑ Caved In ❑ Pit Well ❑ Inactive ❑ e ] Detected/Suspected Well Water Contaminant(s) Adjacent property with contamination(Address) Known Soil/Water contaminants at adjacent property EXISTING WELL CONSTRUCTION DETAILS ❑ Open Bottom Gravel Pack ❑ Uncased ❑ Other-- Well ther_Well Log copy attached ❑ YesNo Grout Seal ElNo Yes __. _It below ground surface(bgs) Hole Diameter inches Well Conductor Casing ❑ Yes No Depth of Conductor Casing ___ __ _____ft gs Diameter of Conductor Casing __ _ inches Well Casing Diameter_ 14, inches Total Depth _O _ft Depth to Water 5W It Depth of Casing _ _ ft bgs DESTRUCTION SPECIFICATION Sealing Material from _ U_ It bgs to _D__ ft bgs Filler Material from ft bgs to ft bgs Well casing to be perforated by one of the following methods: from ft bgs to ft bgs ❑ 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 ❑ without projectile ❑ Other Baling Material Neat Cement(94 lb bag/5-6 gal water) I Sand Cement _ sack mix/7 gal water Bentonite Pellets Bentonite(20°°solids) Manufacturer Spec%solids % Name Specs on File Specs Submitted Placement Method Pumped Free Fall n Other Seal Completion omplete with Mushroom Cap ft bgs ° Complete to Existing Surface Pad V 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. MINI MN HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS CONTRACTORS SIGNATURE TITLE U�kA / DATE i j. . .._ _... ...1..._ -- .. A__. ......._._ ....._....................__ __.. fit, V 3 It < s 1 tP A R T M E N T U S E O N L Application Accepted By _ 3ZL ___ Date �1 Area Destruction Inspection By PIN h� Date 9- /l7 e Employee ID# ,,, COMMENTS �1I&W �,P q- 6&1. ��P�s�`/t �7✓/��lr �iM ►� didf� CSS° PE SC Received ec Amount Permit/ Codes Info B sh emitted Date Service Request# Invoice# Well ID# V EHD 43-08 WELL DESTRUCTION PERMIT 4/30/12