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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 tt 1 JOB ADDRESS (> ALl'T 111 a46�:, f CITY/ZIP Mul1 '/r"cy t�+ ', y�Z49 7� CROSS STREET /rt Si'I t� LLAPN }}_GI �n7 {{PARCEL SIZELAND USE APPLICATION# e OWNER �" �E)-0In(!/ SPG/1 PQ- !-/✓I��iV�' �F' z" PHONE ' OWNER ADDRESS((v-7lh12Fj ;�\.1"(`�l;'t S tC (.' —CITY/STATE/ZIP /y iGi L1.4 r r,� ,M CONTRACTOR f`'0+ P l, f 1) i�I t t, r T :,- PHONE. 2-- (Ci 7 .g / CONTRACTOR ADDRESS ( i r'� /�; Ifo r`� i i 61 CITY/STATE/ZIP W1,,C.I-)y',r W C-57 WELL DRILLING LICENSE NUMBER� L 7-2, 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 ExpiralPA 13 San Joaquin County Sheriff-Coroner Explosives Application and Permit License Number Expir� ❑ California Occupational Safety Health-Blaster License Number Expiretlo REASON FOR DESTRUCTION Dry Replacement Well ❑ Caved In ❑ Pit Well - ❑ 'Inactive AUG 3egt F/,019 Detected/Suspected Well Water Contaminant(s). `J Adjacent property with contamination(Address) OAQ Known Soil/Water contaminants at adjacent property N NME EXISTING WELL CONSTRUCTION DETAILS ❑ Open Bottom 1" Gravel Pack ❑ Uncased ❑ Other _ Well Log copy attached ❑ Yes ❑(No Grout Seal ❑ No ❑ Yes 1t below ground surface(bgs) Hole Diameter inches Well Conductor Casing❑ Yes Ili+No Depth of Conductor Casing ft bgs Diameter of Conductor Casing Inches Well Caging Diameter inches Total Dept it Depth to Water Tt�7ft Depth of Casing ft bgs DESTRUCTION SPECIFICATION Sealing Material from ft bgs to It bgs Filler Material from ft bgs to ft bgs Well casing to be perforated by one of the following methods; from ft bgs to It bgs ❑ Mills Knife —Number of cuts every it and/or ❑ Explosives ❑ Detonating cord ❑ with projectiles every It ❑ without projectile ❑ Detonating cord and boosters ❑ with projectiles every It ❑ without projectile ❑ Other Sealing Material ❑ Neat Cement(94 Ib bag/5-6 gal water)❑ Sand Cement sack mlx17 gal water ❑ Bentonite Pellets ' Bentonite(20%solids) ❑ Manufacturer Spec%solids—% Name ❑ Specs on File E� Specs Submitted Placement Method kl Pumped n Free Fall ❑ Other Seal Completion a Complete with Mushroom Cap It bgs L 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. i8 MINIMUM HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS ty CONTRACTORS SIGNATURE _1—.., c _ TITLE Gl.a..,r,.+,- DATE I ## L I i l r UU N DEP RTMENT USE ONLY 7 Application Accepted By YVy' 1'l ll� '�_ Date '�7 �� Area C) ILI Destruction Inspection By Date Employee ID# AC{Ur COMMENTS PE SC Received chWe Amount Date Permit/ invoice# Well ID# Codes Info B ��sh- Remitted Service Request# 3 it.,lS",oD / /- LJ?On 59 EHD.43;OQWELL DESTRUCTION PERMIT 4~9