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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 1 614(0 'aGUT.1,1 Lit,\ CITY/ZIP M,Akl -ref / 1 [[ ) G�I hh C CROSS STREET APN LUIi_G/ PARCELS IZ1LAND USE APPLICATION# t7 IF('A`v\ `` OWNER hh4 1 i -l°r ''�J"t'"�(C /.I I," PHONE (6 G.. f.S-3 OWNER ADDRESS r'�' '-'�� G 02 CITY/STATE/ZIP(-"Sf Lr o 0a `)r �c1 ` fl CONTRACTOR -r t i l r r( t l\t "-L- PHONE � (61 12 r+ y J 141,d- ,{ t � C NTRACTOR ADDRESS 11,,1 A t for �/ �// CITY/STATE/ZIP p t/(1,d-S�, /, ,J --K Q7C-57 WELL DRILLING LICENSE NUMBER tC�t'7`JtO.t-. - EXPIRATION DATE C/-3 2/ .PERFORATION CONTRACTOR PHONE PERFORATION CONTRACTOR ADDRESS CrTY/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 to ❑ California Occupational Safety Health-Blaster License Number Expiratio REASON FOR DESTRUCTION Dry ❑ eplacement Well ❑ Caved In ❑ Pit WBII ❑ Inactive CD Detected/Suspected Well Water Contaminant(s) o C Adjacent property with contamination(Address) 0 9zvi� Known Soil/Water contaminants at adjacent property ! JeAQ"cAL � EXISTING WELL CONSTRUCTION DETAILS Open Bottom ❑ Gravel Pack ❑ Uncased ❑ Other rN-ATE__ Well Log copy attached ❑ Yes No Grout Seal ❑ No ❑ Yes it below ground surface(bgs) Hole Diameter „�F�M hes Well Conductor Casing❑ Ye)s No Depth of Conductor Casing It b s. Diameter of Conductor Casing _ inches Well Casing Diarneter'lam, inches Total Depth t 4� It Depth to Water �' ft Depth of Casing It bgs DESTRUCTION SPECIFICATION Sealing Material from -0ft bgs to 0 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 it and/or ❑ Explosives❑ Detonating cord ❑ with projectiles every ft ❑ without;projectile [I Detonating cord and boosters ❑ with projectiles every it ❑ without:Projectile ❑ Other Sealing Material ❑ -Neat Cement(94 Ib bag15-6 gal water)R Sand Cement sack mix/7 gal water ❑ Bentonite Pellets Bentonite(20%solids) ❑ Manufacturer Spec%solids_% Name [I Specs on File El Specs Submitted Placement Method tf�soPumped (I Free F ❑ Other Seal Completion)KC Complete with Mushroom Cap ft bgs U 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. zi® MINIMUM>4 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS �r CONTRACTORS SIGNATURE -- '�'" ) 1 rT TfTLE UL�� ht> �� DATE I tt ----------if i — I _ — jar DE ARTMENT USE ON X �G (i' [Y�' �4 G ��__, Date Area ? �� Application Accepted By —--- Destruction Inspection By Date Employee ID*� � " Af COMMENTS PE Sc Received !Chec Amount Date Permit/ Invoice# Well ID# ode I fo B as emitted S rvice Re uest# FNn sa-nR WELL DESTRUCTION PERMIT