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WELL DESTRUCTION PERMIT PUBLIC WATER SYSTEM ❑Yes ❑No SAN JOAQUIN 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 JOB ADDRESS_... ' t� �Iy�jUF`�� -v'�— CITY/ZIP 37/�/ CROSS STREET / / JLZ7 AAPN -i7w 1-/ 7-1 PARCEL SIZEM�AND USE APPLICATION# OWNER �ZL J 1 lAii ]hol -I& 1�1 ,s PFi?NE OWNER ADDRESS 'j — t Nt CITY/STA /ZIP G CONTRACTOR PHONE_ CONTRACTOR ADDRESS / CITY/STATERADDRESS -if/ J` C-57 WELL DRILLING LICENSE NUMBER_ "�L€J sJ y4 EXPIRATION DATE PERFORATION CONTRACTOR PHONE PERFORATION CONTRACTOR ADDRESS 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 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 Contaminant(s) Adjacent property with contamination (Address) Known Soil/Water contaminants at adjacent property---- EXISTING roperty_ _EXISTING WELL CONSTRUCTION DETAILS ❑ Open Bottom ❑ Gravel Pack ❑ Uncased ❑ Other Well Log copy attached ❑ Yes ❑ No Grout Seal ❑ No ❑ Yes _ft below ground surface(bgs) Hole Diameter /! inche Well Conductor Casing ❑ Yes El No Depth of Conductor Casing _ ft bgs Diameter of Conductor C ing -!J i Well Casing Diameter jinches Total Depth �i��ft Depth to Water_ ft Depth of Cas D.q f DESTRUCTION SPECIFICATION DFpgR�Tq� Sealing Material from _ ft bgs to __ _ ft bgs Filler Material from_ _ ft bgs to �ffAj�s Well casing to be perforated by one of the following methods: _ ___from __ _ft bgs to It bgs ❑ Mills Knife _____ Nwnber of cuts every ft and/or ❑ Explosives ❑ Detonating cord ❑ with projectiles every _ It ❑ without projectile ❑ Detonating cord and boosters ❑ with projectiles every _ ft ❑ without projectile ❑ Other Sealing Material Neat Cement(94 lb bag/5-6 gal water) Sand Cement sack rnix/7 gal water I-V Bentonite Pellets Bentonite(20%solids) Manufacturer Spec%solids __% Name----- Specs on File Specs Submitted Placement Method 1-I Pumped 1 Free Fallthe_r Seal Completion Complete with Mushroom Cap~'Z ��2' it bgs"� /v(-`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. VANCE NOTICE REQUIRED FOR INSPECTIONS CONTRACTORS SIGNATURE TITLE rJ�/r//!X/L_ DATE me .... .. _..-.. ..... . - _ .. i _ _ .. ... _ .. _. _ ........ _........f i - -.........._..... - --. ........... — - - - P A R T M E N T U S E O _"y Application Accepted By - __ Date Area Destruction Inspection By Date 0 14 Employee I f� COMMENTS a < 42 PE Sc Received hec Amount Permit/ Codes Info B/ ash Remitted Date Service Request# Invoice# Well ID# 16 wpoo Y65 EHD 43-08 WELL DESTRUCTION PERMIT 4/30/12