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WELL DESTRUCTION PERMIT PUBLIC WATER SYSTEM ❑Yes ❑No SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 600 E MAIN STREET-STOCKTON CA 95202 - (209)468.3420 NON-REFUNDABLE PERMIT / CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS J /r / Ld CITY/ZIP CROSS STREET �-ol l (� APN/g�J /O V PARCEL SIZE_LAND USE APPLIC TION# _ OWNER /-I-,a PHONE n G OWNER ADDRESS CONTRACTOR CITY/STAT CONTRACTOR /�i_[FFrIFF PHONE CONTRACTOR ADDRESS C_J �J[J{ ��/G ,J ) CITY/STATE/ZIP - c3"— - S C-57 WELL DRILLING LICENSE NUMBER (5 �/ tJ� EXPIRATION DATE J I ♦! 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 ❑ Pitwell ❑ Inactive ❑ Test Hole Detected/Suspected Well Water Contaminant(s) Adjacent property with contamination(Address) Known Sc161Nater contaminants at adjacent property I EXISTING WELL CONSTRUCTION DETAILS ❑ Open Bottom ❑ Gravel Pack ❑ Uncased ❑ Other Well Log copy attached ❑ Yes ❑ No Grout Seal ❑ No ❑ Yes__ft below ground surface(bgs) Hole Diameter inches Well Conductor Casing:1 Yes ❑ No Depth of Conductor Casing ft bgs Diameter of Conductor Casing inches Well Casing Diameter_ tInches Total Depth ___ft Depth to Waterft Depth of Casing ft bgs DESTRUCTION SPECIFICATION Sealing Material from ',4 O ft bgs to _ftbgs Filler Material---- _ _.___-__from ft bgs to ft bgs Well casing to be perforated by one of the following methods: from It bgs to ft bgs C 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__, 7— Sealing Material Neat Cement(94/b bag/5-6 gal water) Sand Cement 4' sack mi gal water X Bentonite Pellets Bentonite(20%solids) -- Manufacturer Spec%solids_% Name - Specs on File Specs Submitted Placement Method i Pumped Free Fall Other Seal Completion .x Complete with Mushroom Cap ft gs Comple 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. M IMUM 24 UR ADVANCE NOTICE REQUIRED FOR INSPECTIONS CONTRACTORS SIGNATURE TITLE Lf0�1DATE J ,-;zy pAYMEN7 RECEIVED MAY 2 9 2012 E A M E N T U S E O N L Application Accepted By Date �/ Area �� Destruction Inspection By �� / Date 'moi /�-. Employee p yee ID#_ COMMENTS / /1�C PE SC Received Chec Amount Date Permit] Invoice# Well ID# Codes Info By Cash Pernitted Service Re uest# _, I