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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 EXPIRE/S�1 YEAR/FROM DATE ISSUED JOB ADDRESS O J 3 R,3,A_S16t-N h //�� CITY/ZIP CROSS STREETCleA 4t C' APN 0(OS l")a-6ofV PARCELSIZE -1 j� \ Q LAND USE APPLICATION# OWNER Frtt�M*dZ Rod l t o PHONE (4s5 J 9/05 z OWNER ADDRESS 60-3-S I- mxsS -or R-J, CITY/STATE/ZIP 1i1Ad'--» , ( 4 ` 57-3/o J CONTRACTOR ` Affil* • PHONE _52Z- ItI2_9 CONTRACTOR ADDRESS L L �K PICO, QQ CITY/STATE2IP t d C-57 WELL DRILLING LICENSE NUMBER ��U�� EXPIRATION DATE q-30-7— f PERFORATIO 0- 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 HealZi-Blaster License Number Expiration Date REASON FOR DESTRUCTION Dry Replacement Well ❑ Caved In ❑ Pit Well ❑ Inactive ❑ Test Hole Detected/Suspected Well Water Contaminant(s) Adjacent property with contamination (Address) Known Soil/Water contaminants at adjacent property EXISTING WELL CONSTRUCTION DETAILS ❑ Open Bottom Gravel Pack ❑ Encased ❑ Other Well Log copy attached ❑ Yes X No Grout Seal ❑ No ❑ Yes ft below ground surface(bgs) Hole Diameter inches Well Conductor Casing ❑ f y N No Depth of Conductor Casing It bgs Diameter of Conductor Casing inches Well Casing Diameter $ inches Total Depth -O ' - It Depth to Water__ _S___ It Depth of Casing -. -ft bgs DESTRUCTION SPECIFICATION Sealing Material from -0-1 It bys 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 _ --ft and/or ❑ Explosives ❑ Detonating cord ❑ with projectiles every _ft ❑ without projectile ❑ Detonating cord and boosters ❑ with projectiles every _ft ❑ without projectile ❑ Other Sea'ng Material Neat Cement(941b bag/5 6 gal water) Sand Cement sack mixl7 gal water Bentonite Pellets Bentonite(20%solids) Manufacturer Spec%solids _ °-o Name Specs on File Specs Submitted Placement Method Pumped x Free Fall 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, LIS MUM XHOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS CONTRACTORS SIGNATURE TITLE 0'-AJ'i DATE sv w ;a t ....... . _... _... _ _� 1Ao�s PAYMENT_ E RECEIv I A 2 8 2099 ,SAN JOAQUIN COUNTY i.- - ---f_ r..__.__ _. _--•-.-- _ I-._ _ ...__ _ ... ._.... ____.._ ' _ ___._ __ — ENVIRONMENTAL E HEALTH DEPARTMENT i � I . _...........__........._...... ---.. _......-- - - — - .. AR MENT USE ON Y / /� Application Accepted By " > Date G Area "l Destruction Inspection Byw�__ �U�� -E�->_--- .------- DZ161 � Q - --- Employee IDfi // rr---- II GI n L / / C} COMMENTS 1 ,V-O +t j Ltd lit 6e/VV+,[tel! � �2�� lb! 11 PE SC Received Check#/ Amount 1 Permit/ Date Invoice# Well ID# Codes Info B CPs h emitted I Service Re uest# E H D 43-08 WELL DESTRUCTION PERMIT 4/30/12