WP0040151 - Laserfiche WebLink

Home Browse Search

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 t CALL 209 953-7697 FOR INSPECTION E PIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS 2-C3 /� � �� f-23? r-I CROSS STREET AP ��'C L PAR/C/EL . LAND USE APPLICATION# C OWNER t ONE �/ ^ �� `/0 C OWNER ADDRESS /, J CITY/STATEIZIP 5-(0 S-61 % !�U/ {� C' ` •J CONTRACTOR Pad f'1 C click W .1(and� v PHONE �J`y S-B 1 �000/� ,J 1�'{ CONTRACTOR ADDRESS 2-70K CITY/STATEIZIP J OI n \ C�nn C`Y� `� (,� `��J� . 1 C-57 WELL DRILLING LICENSE NUMBER 71 EXPIRATION DATE PERFORATION CONTRACTOR PHONE PERFORATION CONTRACTOR ADDRESS CITY/STATEIZIP _ C-57 Well Drilling License Number J:�)jt)frel Expiration Date Bureau of Alcohol,Tobacco and Firearms-Users of High Explosives License Number Expiration Date G 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 Contaminants) 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 ❑ ti„ Yes'�I ft below ground surface(bgs) Hole Diameter�_inches Well Conductor Casing Yes ❑ No Depth of Conductor,Casing ft bgs Diameter of Conductor Casing r.� inches 7� Well Casing Diameter_�l','_inches Total Depth�ft Depth to Water_ft Depth of Casing It bgs DI:ti I-ImcrION SPECIFICATION 11 t- Sealing Material from t ftbgs to_I " , ftbgs Filler Materiel I' ^ . I ft bgs to 1 ft bgs Well casing to be perforated by one of the following methods: om ftbgs to ftbgs ❑ 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 CN.at Cement(g4 Ib beg/5-6 gal water) Sand Cement sack mix l7 gal water Bentonite Pellets Bentonite(20%solids) Manufacturer Spec%solids_% Name Specs on Fite Specs Submitted Placement Method Pumped 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. t 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. MINIJ+A 48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS /lam !A�t/ 7/ CONTRACTORS SIGNATURE �ry TYRE �U � DATE ) y `1 iJ { � cFBV�� ✓�S� T 0 X019 Tho gR�T�,q�IV�Y MFNT EP RTMENT USE O L Application Accepted By Date Area Destruction In coon By �✓ Date EmploJ1D# COMME TS 'rJ1 t (rte PE SC Received Chock* Amount Date Permltl Invoice# Well ID# Codes Info Cas Remitted Service Re uest# li ^ o I s I EHD 43-08 WELL DESTRUCTION PERMIT revised 4/14/18