WP0040010 - Laserfiche WebLink

Home Browse Search

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 //�� n JOB ADDRESS 309 �Lgr.,� •e ei CITY/ZIP Vol `► 7�� CROSS STREET 2n`— APN I � PARCEL SIZEWAND USE APPLICATION# OWNER 40JA . 41411 Q 4 PHONE ��— 3 m OWNER ADDRES G CITY/STATE21PV ,*/-, r CONTRACTOR11�3a7_ PHONE SZ Z D CQNTRACTOR ADDRESS—1 i,q b floi S CITY/STATE2v 1P -C 1 C4 `J \f�C'_ 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 X 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 Gravel Pack ❑ Uncased ❑ Other Well Log copy attached ❑ Yes No Grout Seal ❑ No Yes It below ground surface(bgs) Hole Diameter inches Well Conductor Casing ❑ Yes _�<No Depth of Conductor Casing It bgs Diameter of Conductor Casing inches Well Casing Diameter__inches Total Depth _71Q -ft Depth to Water-775—ft Depth of Casing ft bgs DESTRUCTION SPECIFICATION Sealing Material from 6 --ft bgs to 77 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 Sealing Material Neat Cement(94 Ib bag/5-6 gal water) Sand Cement sack mixll gal water Bentonite Pellets Bentonite R %solids) Manufacturer Spec%solids—% Name Specs on File Specs Submitted a ement M od� Pumped Free F i Other Seal Completion Complete with Mushroom Cap 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. M XH OUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS CONTRACTORS SIGNATURE TITLE 40Z"Nl#e DATE —2-6+/ E: .._... ..... PAYMENT . ;...... ...._.._...... .... ._......_... ... .......... _.......... _._. ...._ .RECEIVED - _.. __......__... . AUG 2 8 2019 - — -- SAN JOAQUIN COUNTY _ NVIRONMENTAL E HEALTH DEPARTMENT _...__ .._._.. .-.._ ___.... ........ .. . _-.-- ........... ..._.,....._.. ........._ .. ........._.. ._..... - - - — - ....... AUG 2 8 2019 .........._............. ........ _.._......_. . - _....... ....... -- - — ENVIRONMENTAL j11--i'.E_7' _ PERM:[.x i I _ Tq— I I_ - 0.E ARTM ENT USE ONLY A Application Accepted B Date "21h Area 1. Destruction Inspection By _ Date Employee ID# COMMENTS VV -I LAXI Ol'f' Q l�V S I�vOI�{'� .I !C d e A-e l 6,vtA l vct ,,w A a lA l0 PE SC Received Check#/ Amount Permit/Codes Info B Cash mitted Date Service Request# Invoice# Well ID# EHD 43-08 WELL DESTRUCTION PERMIT 4/30/12