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WELL DESTRUCTION PERMIT <br /> PUBLIC WATER SYSTEM ❑Yes ❑No <br /> SAN JOAOUIN 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 1 YEAR FROM DATE ISSUED <br /> A� r <br /> JOB ADDRESS Zl (/V & CITY/ZIP 7,1 <br /> CROSS STREET R l ('t pp,���.{� APN &' PARCEL SIZE/ 1 LAND USE APPLICATION# <br /> OWNER �jOl.ft9LI �F—vvY`ytt PHONE <br /> OWNER ADDRESS O CITY/STATE/ZIP <br /> CONTRACTOR l b—_ I� U PHONE <br /> CONTRACTOR ADDRESS V ` L/� CITY/STATE/ZIP / ,) ,� <br /> C-57 WELL DRILLING LICENSE NUMBER 6 EXPIRATION DATE A;i, <br /> PERFORATION CONTRACTOR L` 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 ❑ <br /> Well Log copy attached ❑ Yes I11,No Grout Seal ❑ No ❑ Yes ft below ground surface(bgs) Hole Diameter inches <br /> Well Conductor Casing ❑ Yes 41 No Depth of Conductor Casing __ _ _. _ft bgs Diameter of Conductor Casinginches <br /> Well Casing Diameter ,t+___inches Total Depth f f�ft Depth to Water-100 it Depth of Casing it bgs <br /> DESTRUCTION SPECIFICATION t K,- CCV// l <br /> Sealing Material from _ ft hgs to 00 It bgs Filler Material __ 1�F�V� from�ft bgs to ff_!�­ft bgs <br /> Wel casing to be�erfora <br /> d by one of the followin methods: from ft bgs to ft bgs <br /> ills Knife Number of cuts every______._____ft and/or <br /> ❑ Explosives ating 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 bag/5-6 gal water) KSand Cement 1_0.?__sack mixh gal water Bentonite Pellets <br /> Bentonite(20%solids) Manufacturer Spec%solids % Name --- Specs on File Specs Submitted <br /> Placement Method Pumped Free Fall t Other <br /> Seal Completion N <br /> Complete with Mushroom Cap 7 ft bgs 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. <br /> IM NIMU HOU , E NOTICE REQUIRED F*NSPECTIONS <br /> CONTRACTORS SIGNATURE TITLE rr DAT "1 7 <br /> f <br /> 1�2 <br /> E <br /> _ ... ............................_..........................................__.........._.................................... - _ _ ............. <br /> i t <br /> I <br /> PAYMENT '- <br /> - RECEIVED -r- <br /> .._......_....--- .._..__ ........_......._.._ -. _ _.._._... _--- ---.. <br /> _........._..... - <br /> t. - -- AUG 16 2019 <br /> I I _ f SAN JOAQUIN COUNTY,,-- <br /> 3 ! . <br /> ENVIRON <br /> EP RTMEN THE J IJV DbPAFyN4ENT �+ <br /> Application Accepted By _ __. _ _ _ Date Area <br /> Destruction Inspection B _ Date �L Employee ID# <br /> COMMENTS (b <br /> J <br /> PE SC Received heck Amount Permit/ <br /> Date Invoice# Well ID# <br /> Codes Info By Cash Fiemitted � WService Request# _ <br /> 3;z-Iss <br /> EHD 43-08 WELL DESTRUCT ION PERMIT <br /> 4/30/12 <br />