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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 '(,){ �_[i gj CITY/ZIP t J J CROSS STREET IIf•7^a�•i'�^�"'�"�' �T jv C�1( APN '�i-`°,ct+/"5--� Y PARCEL SIZE�LAND USE APPLICATION# d OWNER �,tiq,�l r') -PUt� I4e 114' l/{�')-f/1 @=. P`! PHONE-'-'.,-i 3 ' 1 k:-4, OWNER ADDRESS' i 7 v 4 i (.e�' �" f� t%{ —CITY/STATE/ZIP f_�« CONTRACTOR 1`A P lI, ( r)F ;L�,ii„f 7 i,,r PHONE r 2 - n)�1 C) ( -� CONTRACTOR ADDRESS ((.-{ 47.Q(t °- ,C f•� CITY/$TATE2IP }�'v`�;:.� 1 - C-57 WELL DRILLING LICENSE NUMBER 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 ,ly 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 WELL CONSTRUCTION DETAILS ❑ Open Bottom `Y "Gravel Pack. ❑ Uncased ❑ Other Well Log copy attached ❑ Yes No Grout Seal ❑ No ❑ Yes ft below ground surface(bgs) Hole Diameter Inches Well Conductor Casing❑ Yes `I No'" Depth of Conductor Casing ft bgs Diameter of Conductor Casing Inches Well Casing Diameter" -,r Inches Total Depth l r:' it Depth to Water ft 'Depth of Casing ft bgs DESTRUCTION SPECIFICATION Sealing Material from It bgs to—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 It ❑ without projectile ❑ Other Sealing Material ❑ Neat Cement(94/b bag/5-6 gal water)U Sand Cement sack min/7 gal water ❑ Bentonite Pellets \,V Bentonite(20%solids) ❑ Manufacturer Spec%solids_% Name ❑ Specs on File [J Specs Submitted Placement Method Pumped ❑ Free Fall s r] Other Seal CompletloComplete with Mushroom Cap l ,' It 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. „AINIMUM A HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS CONTRACTORS SIGNATURE TITLE 0:,., y/' DATE �f Y�f�>_✓i I ^ .Q 1i U U _ — Lm. O T E M fJ #1 1 ID / . D..E/PARTMENT USE ONLY 1 Application Accepted By i� � � Date c1' � � Area T Destruction Inspection By Date Employee ID# ! ',11 -� - /A COMMENTS PE SC_ Received Check#/ Amount Permit/ Codes Info B Cash Remitted Date Service Re uest# Invoice# Well ID# EHD 43-08 WELL DESTRUCTION PERMIT