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WELL DESTRUCTION PERMIT PUBLIC WATER SYSTEM ❑Yes j]No SAN JOAOUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 East Hazelton Avenue-STOCKTON CA 95205 - (209)468-3420 NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS 4. E PIKES 1 YEAR FROM DATE ISSUED p � S3 JOB ADDRESS / O / 5,1 I'- L CITY/ZIP ,' t/Q► m CROSS STREET """ray A P N — O PARCEL SIZE(J.'fT AND US APPLICATION# OWNER 4 �.� PHONE / OWNER ADDRESS CITY/STATE/ZIP&&4Ynna CONTRACTOR d PHONE 7—,P7 ZJ— 3/ ZG CONTRACTOR ADDRESSCITY/STATE/ZIP Ldr� f SL `7 ❑ C-57 WELL DRILLING LICENSE NUMBER / iF 1,2 3 EXPIRATION DATE Z,&Lo 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 Health-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 ❑ Uncased ❑ Other _ Well Log copy attached ❑ Yes ❑ No Grout Seal ❑ No ❑ Yes . ____It below ground surface(bgs) Hole Diameter inches Well Conductor Casing ❑ Yes ❑ No Depth of Conductor Casing It bgs Diameter of Conductor Casing _ inches Well Casing Diameter . G __inches Total Depth 6.O ft Depth to Water__. ft Depth of Casing ft bgs DESTRUCTION SPECIFICATION Sealing Material from 6..Q ft bys to �� ft bgs Filler Material OSa C— 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 Sealing Material Neat Cement(94 lb bag/5-6 gal water) Sand Cement sack mix/7 gal water Bentonite Pellets Bentonite(20%solids) Manufacturer Spec%solids % Name Specs on File Specs Submitted Placement Method Pumped Free Fall Fl 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. MIN UM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS CONTRACTORS SIGNATURE /� TITLE_ / / DATE I f i ...._..... ......................... ... ..._...............__....._ __ .. ... .. .. .. .. ... I s [—1-- — ._;......_....... --- RECOV _ _ . �- - ..._. __._... -- _.. _ ;fit' 11 20191 f SAN JOAQUIN COUNTY _.__ __.f. .. .....t_.__......._.. ._..._.._..-_........._......................_._.._._ ._....._..._._._.__.._...._.__....�__ _.__. __.___._...__.____.__.._ ...................._._............ ENVIRONMENTAL HEALTH DEPARTMENT E P R T M E N TU S E Y12- Application Accepted By Date-_ � AreaDestruction Inspection By Date Employee D# COMMENTS r PE SC Received eck#/ Amount Date Permit/ Invoice# Well ID# Codes Info B Cash Remitted Service Request# q�f1-s$ 15 l EHD 43-05 WELL DESTRUCTION PERMIT 4/30/12