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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 41 10-P VN (1 uk 1 —CITY/ZIP CROSSSTREET`'•lc,r J� 'AA�!! AP ' i �Y 5 f7 moi!%=•� PARCEL SIZE/«.,iC.LAND USE APPLICATION# a$ OWNER r /�5%1 Y'�. �' L'J�"I 9r'1 - .;1 ;-� :.^ qj PHONE (.,0 OWNER ADDRESS/,J7. Y��!-�'' I iZ.r%{, CITY/STATErzIPF?��'J/i Y"Y (�Fy p,r�.j1J(.'� ' CONTRACTOR & A S� i! T j(1 1 t,{'� ! in( PHONE �i.c�..^ .:��7,[- G CONTRACTOR ADDRESS ' I { � rL��'' ' IZ,fI CITY/STATE/ZIPr pp��Y'1�ur.}'"S��' r�n �J,!�; J Q C-57 WELL DRILLING LICENSE NUMBER �1�� EXPIRATION DATE PERFORATION CONTRACTOR - PHONE PERFORATION CONTRACTOR ADDRESS CITY/STATE/ZIP N ❑ C-57 Well Drilling License Number Expiration Date �1y-ED ❑ Bureau of Alcohol,Tobacco and Firearms-Users of High Explosives License Number Expire i)Da2 ❑ CHP Hazardous Material Transportation for Explosives License Number EKpjr;�ti0 Date ❑ San Joaquin County Sheriff-Coroner Explosives Application and Permit License Number Expi ❑ California Occupational Safety Health-Blaster License Number �fEUt "•'T REASON FOR DESTRUCTION ❑ Dry ❑ Replacement Well Caved In ❑ Pit Well ❑ Inactive ❑ Test o T Detected/Suspected Well Water Contaminant(s) Adjacent property with contamination(Address) Known Soil/Water contaminants at adjacent property EXISTING WELL CONSTRUCTION DETAILS ❑ Open Bottom ;'til Gravel Pack ❑ Uncased ❑ Other Well Log copy attached ❑ Yes ❑ No Grout Seal ❑ No ,0 Yes/, <,' it below ground surface(bgs) Hole Diameter Inches Well Conductor Casing❑/Yet ❑ No Depth of Conductor Casing ft bgs Diameter of Conductor Casing inches Well Casing Diameter's Kf inches Total Depth it Depth to Water<' ;> It Depth of Casing it bgs DESTRUCTION SPECIFICATION Sealing Material from '% > ft bgs to ? ft bgs Filler Material from It bgs to It bgs Well casing to be perforated by one of the following methods: from It 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 it ❑ without projectile ❑ Other Sealing Material C Neat Cement(94 Ib bag/5-6 gal water)❑ Sand Cement sack mix/7 gal water ❑ Bentonite Pellets 0 Bentonite(20%solids) ❑ Manufacturer Spec%solids % Name ❑ Specs on File ❑ Specs Submitted Placement Method %`b Pumped ❑ Free Fal) ❑ Other Seal Completion L Complete with Mushroom Cap 31 It bgs ❑ Complete to Existing Surface Pad I HEREBY CERTIFY THAT 1 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. y8 M,"MUM�4! HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS CONTRACTORS SIGNATURE �""--~ TITLE G > DATE r V L x (J D-E ARTMENT USE ONYY `` Application Accepted By 1p ,t'll -•-c Wil" � L Date �r %°I Area�� C Destruction Inspection By Date Employee COMMENTS PE SC ReceivedAmount Date Permit/ Invoice# Well ID# Codes Info B �Cash Remitted Service'Request# EHD4M8 WELL DESTRUCTION PERMIT