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WELL DESTRUCTION PERMIT PUBLIC WATER SYSTEM ❑Yes ❑No SAN JOAOUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 East Hazelton Avenue-STOCKTON CA 95205 - (209)468-3420 NON-REFUNDABLE PERMIT C ( CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS rq 97 J!i e►R CITY/ZIP - cat/o» Q CROSS STREET �o APN Z{l°No3o�Zb� PARCEL SIZE/IQAIAND USE APPLICATION# OWNE r n1 e., &A PHONE Q Q z OWNER ADDRESS S c�Yt e - CITY/STAT`EIZIP- iCA, CONTRACTOR et SC I I )�,I Dr l)I )'1N ' 51( ' PHONE J22/"�1p2_4 p CONTRACTOR ADDRESS I A`��✓S ,V1 CITY/STATE/ZIP C, ' -� C-57 WELL DRILLING LICENSE NUMBER Wn% EXPIRATION DATE PERFORATION CONTRACTOR PHONE PERFORATION CONTRACTOR ADDRESS CITY/STATE/ZIP ❑ C-57 Well Drilling License Number Expirati�� ❑ Bureau of Alcohol,Tobacco and Firearms-Users of High Explosives License Number Expiration' ❑ CHP Hazardous Material Transportation for Explosives License Number ExpiratrPat 11 San Joaquin County Sheriff-Coroner Explosives Application and Permit License Number Expiration Dat ?nsn ❑ California Occupational Safety Health-Blaster License Number REASON FOR DESTRUCTION ❑ Dry ❑ Replacement Well Caved In ❑ Pit Well ❑ Inacti�Eq�T � Detected/Suspected Well Water Contaminant(s) EpART/yf�� Adjacent property with contamination (Address) Known Soil/Water contaminants at adjacent property_____ EXISTING WELL CONSTRUCTION DETAILS ❑ Open Bottorn Gravel Pac� ❑ Uncased ❑ Other Well Log copy attached ❑ Yes ❑ No Grout Seal ❑ No Yes[0.0-ft below ground surface(bgs) Hole Diameter_ inches Well Conductor Casing ❑ ,Yes ❑ No Depth of Conductor Cas' It bgs Diameter of Conductor Casing inches Well Casing Diameter �T/• inches Total Depth,&-5 IrJJt SDepth to Water1js __ ft Depth of Casing _ ft bgs DESTRUCTION SPECIFICATION Sealing Material from ft bgs to O It bgs Filler Material from ft bgs to _ ft bgs Well casing to be perforated by one of the following methods: ___ from_ R 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/b bag/5-6 gal water) Sand Cement sack mix/1 gal water Bentonite Pellets Bentonite(20% olids) Manufacturer Spec%solids % Name _ _ Specs on File Specs Submitted Placement Method Pumped Fre Falj P 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. 4/8 MI IMUM �4 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS / CONTRACTORS SIGNATURE TITLE �/Z�-gyp / DATE q, 2G,r 0 I � 3 i..._ .. ._..-{_._ _.._..-......._..... ._..... ._. - _...j.»»,...._. .»,.. m _ .. _ .. .. _ i ................... _._... ....__..._....._._...._..._.._._........_.........................._ ._. ._._ ..........._»._........._...._......... ... ..... ._ __..........................._..........__...._.._..... __ .._...._. ....... ...._ .__. _.»_ _ _ ................. ...... ..................... ........... A.._..._.t.._.-.,. ._.. _..... _ .. DE A R T M E N T U S E O N Y Application Accepted By. _ Date_ (` ? / Area Destruction Inspection By Date Employee ID# COMMENTS PE SC Received Amount Date Permit/ Invoice# Well ID# Codes Info B Cash Remitted Service Request# 37773 llqL °I- - EHD 43-08 WELL DESTRUCTION PERMIT 4/30/12