WP0040056 - 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 JOB ADDRESS 1642, G/ CITY/ZIP K C"l336 ��(( Y CROSS STREET APN j-G`?G' G D PARCEL SIZZ162 LAND USE APPLICATION# OWNER Y� Cr PHONE `51O- ,85 Tr OWNER ADDRESS •V • S6 Z CITY/STATE/ZIP C_a ro f CONTRACTOR SCI T f PHONE (-n`N�TRACTOR ADDRESS— LCITY/STATE/ZIP O O Ips 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 Expirati REASON FOR DESTRUCTION Dry ❑ eplacement Well ❑ Caved In ❑ Pit Well ❑ Inactive S Detected/Suspected Well Wa�erContaminan (s) �IV�� Adjacent property with contamination(Address) Known Soil/Water contaminants at adjacent property U 14 A10 EXISTING WELL CONSTRUCTION DETAILS 7c1 Open Bottom [IGravel Pack ❑ Uncased ❑ ¢ '1, V/R_ONw. -, UN_7�_ - rAL Well Log copy attached ❑ Yesfo o Grout Seal ❑ No ❑ Yes ft below ground surface(bgs) Hole DiametRiF_ Il�rPches Well Conductor Casing El Yes Depth of Conductor Casing ft bgs, Diameter of Conductor Casing inches Well Casing Diameter inches Total Depthft Depth to WaterftDepth of Casing ft bgs DESTRUCTION SPECIFICATION Sealing Material from 0 It bgs to 5 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 lb bag/5-6 gal water) Sand Cement sack mixll gal water Bentonite Pellets Bentonite(20%solids) Manufacturer Spec%solids__ _% Name Specs on File Specs Submitted Placement Method x Pumped Free Fall 1 Other Seal Completion Complete with Mushroom Cap _ _ _ It bgs I ' 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. MINIMUM HOUR ADVANCE NOTICE REQUIRED FMOR INSPECTIONS //� CONTRACTORS SIGNATURE LEyW K& DATE �-6-11 _. ..._. _ ..... .._ ------- ..... - ..._ _.. . ----- — - ....... ........._... - '\am� b� .... - -- ' I i I(o D € ARTMENT USE 0 N L Application Accepted By _ Date Area Destruction Inspection By y ��C9t�/\� Date Employee ID# COMMENTS� t91 C i_t- PE SC Received hec Amount Permit/ Codes Info B ash emitted Date S rvice Request# Invoice# Well ID# EHD 43-08 WELL DESTRUCTION PERMIT 4/30/12