Laserfiche WebLink
Rft.a WELL DESTRUCTION PERMIT <br /> } PUBLIC WATER SYSTEM [:]Yes ❑NO <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 East Hazelton Avenue-STOCKTON CA 95205-(209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1YEAR FROM DATE ISSUED <br /> JOB ADDRESS - C)r`.)� �1�ion, .�F'P\ I?.,'l CITY/ZIP3 <br /> IP r� <br /> d <br /> CROSS STREET �" APN r?h".+��'7 �) 'Il d i�f(� PARCEL SlE{LAND USE APPLICATION# e <br /> -r- f�Ea.—�"" t J <br /> OWNER—Y-f_°Ct(i C `�R,a i�-0,ih) `` PHONE `_�?) <br /> OWNER ADDRESS ,ice �- ")�, "A CITY/STATE/ZIP <br /> ` r�j <br /> CONTRACTOR-41'-11: '1'I I I r 1v, r PHONE���i� ('1 i 9 <br /> � / Y' <br /> CONTRACTOR ADDRESS �) I Y7 P'!<y §� A.,.. CITY/STATE/ZIP [Gil�'e!A f�_57'!.: n cl (y�S-_d <br /> I C-57 WELL DRILLING LICENSE NUMBER� EXPIRATION DATE <br /> PERFORATION CONTRACTOR PHONE <br /> PERFORATION CONTRACTOR ADDRESS CITY/STATE/ZIP <br /> ❑ C-57 Well Drilling License Number Expiration Date <br /> ❑ Bureau Of Alcohol,Tobacco and Firearms-Users of High Explosives License Number Expiration Date <br /> ❑ CHP Hazardous Material Transportation for Explosives License Number Expiration Date <br /> ❑ San Joaquin County Sheriff-Coroner Explosives Application and Permit License Number Expiration Date <br /> ❑ California Occupational Safety Health-Blaster License Number Expiration Date <br /> REASON FOR DESTRUCTION Dry Replacement.Well. ❑ Caved In ❑ Pit Well ❑ Inactive ❑ Test Hole <br /> Detected/Suspected Well Water Contaminant(s) <br /> Adjacent property with contamination(Address) <br /> Known Soil/Water contaminants at adjacent property <br /> EXISTING WELL CONSTRUCTION DETAILS ❑ Open Bottom Gravel Pack ❑ Uncased ❑ Other <br /> Well Log copy attached ❑ Yes �(No Grout Seal ❑ No ❑` Yes It below ground surface(bgs) Hole Diameter Inches <br /> Well Conductor Casing❑ Yes'i� No Depth of Conductor Casing ft bgs Diameter of Conductor Casing Inches <br /> Well Casing Diameter inches Total Depth Of , ft Depth to Water--!' _It Depth of Casing If bgs <br /> DESTRUCTION SPECIFICATION <br /> Sealing Material from c 7 j flogs to f) ft bgs Filler Material - from It bgs to ft bgs <br /> Well casing to be perforated by one of the following methods: from ft bgs to ft bgs <br /> ❑ Mills Knife Number of cuts every ft and/or <br /> ❑ Explosives❑ Detonating cord ❑ with projectiles every ft ❑ without projectile <br /> ❑ Detonating cord and boosters ❑ with projectiles every ft ❑ without projectile <br /> ❑ Other <br /> Sealing Material ❑ Neat Cement(94 Ib bag15-6 gal water)P Sand Cement sack mix/7 gal water Bentonite Pellets <br /> _ W Bentonite(20%solids) ❑ Manufacturer Spec%solids_% `Name ❑ Specs on File ❑ Specs Submitted <br /> Placement Method rl Pumped X Free Fall ❑ Other <br /> Seal Completion [! Complete with Mushroom Cap It bgs LJ Complete to Existing Surface Pad <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. QQ <br /> �P <br /> MINIMUM;<HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br /> CONTRACTORS SIGNATURE - _ TITLE -u r., DATE <br /> J. <br /> ) <br /> low <br /> T^^ <br /> iF <br /> U _-�,8 2(19---1 <br /> w-i*c <br /> 19- <br /> i*c l`JI O <br /> L- <br /> VT TEN F <br /> p,EE,PART,MENT USE ON Y 1bp'( <br /> Application Accepted By r /�cf� Date yO Area <br /> Destruction Inspection By Date Employee ID# <br /> COMMENTS <br /> PE SC Received Check#/ Amount Permit/ <br /> Codes Info B Cash Remitted Date Service Re uest# Invoice# Well ID# <br /> 143-08 WELL DESTRUCTION PERMIT <br />