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WELL DESTRUCTION PERMIT { PUBLIC WATER SYSTEM ❑Yes ❑No SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPT 1868 East Hazelton Avenue-STOCKTON CA 95205-6232 -(209)468-3420 NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS J 76,WL0.11114 9 CITY/ZIP p / CROSS STREET •� �O i1 APN�,S t F7(D O 27 PARCEL SIZ AND USE APPLICATION# � O A OWNER VA 1VTOL, F CrT PHONE v OWNER ADDRESS ) 1 CITY/STATE/ZIP ✓( iI C,4 4 S3 6 ( 1/ r.r CONTRACTORC" PHONE CONTRACTOCITY/STATE/ZIP Z L-/OC 0V 7 (-557 �J�G WELL DRILLING LICENSE NUMBER 5/3 y 2� EXPIRATION DATE 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 49-IMtive ❑ 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 fid'No Grout Seal ❑ No ❑ Yes ft below ground surface(bgs) Hole Diameter inches Well Conductor Casing❑ Yes 0—No Depth of Conductor Casing ft bgs Diameter of Conductor Casing inches Well Casing Diameter inches Total Depth�9ft Depth to Water 2-5 ft Depth of Casing (n® ft bgs DESTRUCTIONSPECIFICATION Sealing Material from ._J�3 ft bgs to_6&ft bgs Filler Material 110 from rPft bgs to ft 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 ft ❑ without projectile ❑ Other A L Sealing Material Neat Cement(94 Ib bag/5-6 gal water) Sand Cement sack mix/7 gal water Bentonite Pellets r LAentonite(20%solids) Manufacturer Spec%solids % Name Specs on File Specs Submitted Placement Method ol�fu`mped Fre F 'VA® er O O Seal Completion e e wl Complete to Existing Surface Pad d c 1 HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLIC TION AND THAT THE WORK WILL BE DONE IN ACCORDANCEAN JOAQUIN COUNTY ORD[ NCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICE fl�qD�J CURRENT AND ACTIVE TH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANC �U�h J WORKERS COMPENSATI LAWS. INI H UR ADVANCE NOTICE REQUIRED FOR INSPE TIONS `� NO p'9 TMFN CONTRACTORS SIGNATURE TITL 7 DATE 3- t S ....... .;......... . ..... jr,toe i .:. i .. �. ! e , v ..i....... , ..:.... .. ..... P-A MENT USE ONL f Application Accepted ByAlmaA Date Area 194V 1 t t Destruction Inspection By Date t! /9 Employee ID# COMMENTS S `r AT L '_\ vj liw V 1 l PE SC Received Amount D to Permit/ Invoice# Well[D# Codes Info By- Cash Remitted Service Request# 72Z� O EHD 43-08 WELL DESTRUCTION PERMIT revised 4/14/18