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WELL DESTRUCTION PERMIT O PUBLIC WATER SYSTEM [3 Yes SXl SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 600 E MAIN STREET-STOCKTON CA 95202-(209)468-3420 NON-REFUNDABLE PERMIT CALL 209 1953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS < < / CrrY1Z1P ��I.CGk� - (S 2-3 CROSSSTREET�_ 11 N193— '0-70 -02— PARCEL SIZE II_a tIAND USE ZPLICATION# i OWNER ` PHONE T OWNER ADDRESS CITYISTATE/ZIP 19-e 640^ �.,T !s fd -ZIZZ1 O CONTRACTOR PHONE A CONTRACTOR ADDR L CITY/STATE/ZIP R." cij-.. L{ry X C-57 WELL DRILLING LICENSE NUMBER { S -7 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 ❑ Inactive ❑ Test Hole Detected/Suspected Well Water Contaminant(s) Adjacent property with contamination(Address) Known SoiUWater contaminants at adjacent property o 1 EXISTING WELL CONSTRUCTION DETAILS ❑ Open Bottom ❑ Gravel Pack ❑ Uncased ❑ Other_ N Well Log copy attached ❑ Yes ❑ No Grout Seal ❑ No ❑ Yes ft below ground surface(bgs) Hole Diameter inches 'vnl Well Conductor Casing❑ Yes ❑ No Depth of Conductor Casing ft bgs Diameter of Conductor Casing Inches rn Well Casing Diameter inches Total Depth ft Depth to Water It Depth of Casing ft bgs DESTRUCTION SPECIFICATION Sealing Material from 2-4 It bgs to ft bgs Filler Material from ft bgs to ft bgs (� Well casing to be perforated by one of the following methods: from ft bgs to ft bgs (tC►` ❑ Mills Knife Number of cuts every ft and/or ❑ Explosives❑ Detonating cord ❑ With projectiles every It ❑ without projectile �I ❑ Detonating cord and boosters ❑ With projectiles everyft ❑ without projectile ❑ Other /_ Sealing Material Neat Cement(941b bag/S6IL) 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 Other Seal Completion X Complete with Mushroom Cap Com_r�t�r J' ft bgs mplete o istin S ct Pad I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THEW RK WILL BE DONE IN ACC DANCE 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 IM/UM24HO ADVANCE NOTICE REQUIRED FOR INSPECTIONS // 7 7 CONTRACTOR SIGNATURE 7�- TITLE ee_x.�/ DATE I �L 4 b mel/To PAYMENT RECEIVED `, APR 2 12012 U �yp�iw-n:�YT'f DEPARTMENT USE ONLY Y"79 Application Accepted By ate Area Destruction Inspection By Date 3 Z Employee ID#_4 04{— COMMENTS ffGL(Sl S Lc PE SC Received ount D to Perrin-V Invoice# Well ID# Codes Info B CSGeSh� Remitted Service R uest# 3 3 S? c?J G -19-7