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CONTRACTORS SIGNATU E MINIMUM 24 HOUR ADVANCE NOTICE REOUED.FOR INSPECTIONS - ( 0 C TITLE 1-- r Application Accepted By Destruction Inspection By COMMENTS 6 USE ONLY,/ Date 5' I Area r -11/1( Employee ID# C CLI DEPARTMENT rt, dec: 4 tiVe".1e- ;L- t. 115 WELL DESTRUCTION PERMIT PUBUC WATER SYSTEM [(Yes No SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 East Hazelton Avenue - STOCKTON CA 95205 - (209)468-3420 NON-REFUNDABLE PERMII CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED k .1-Al 0(....- CrreiZiP \C „- -, JOB ADDRESS ---4(.12 c - C) vt 1(4)c-IA U-A i C.44 1C,-; 2) -1-1 CROSS STREET SCV.V.) \ II--e..., APN '-'-',1 \ I f-' '-.1. PARCEL SIZE c-I-LAND USE APPLICATION A OWNER (.1‘) \ (LINN /_., AAC...41(ZrA PHONE C-- \ CJ 7 -11 Li •- CI?) „I OWNER ADDRESS .---A(.i Cie: I vs.co'ck..A iZA.CITY/STATE/ZIP -1"cscAs.:),..i (J2,- c:t S-73 7 7 CONTRACTOR Kej„),,,N ...\17:34.1:-.4..c:-.. VI.-M,1) T.' 1.:Jeltnid t. L.,_..4. k PHONE C. - S q. ,) , ,) ,:-/ - -1,k / (47 CCATRACTOR ADDRESS Q. ci-,--2,c)( i...,c, \ Cm/STATE/ZIP PIK key.), 04 qc-,:ii-; 01 C-57 WELL DRILLING LICENSE NUMBERc-1/Ve_.,' 5 g ..., EXPIRATION DATE C) /3 / / .":7 c I -7 PERFORATION CONTRACTOR PHONE PERFORATION CONTRACTOR ADDRESS CITY/STATE/ZIP *..:JC..5..7-WErfl-ariffrnty License Number Expiration Date 0 Bureau of Alcohol, Tobacco and Firearms - Users of High Explosives License Number Expiration Date 0 CHP Hazardous Material Transportation for Explosives License Number Expiration Date 0 San Joaquin County Sheriff-Coroner Explosives Application and Permit License Number Expiration Date 0 California Occupational Safety Health - Blaster License Number Expiration Date REASON FOR DESTRUCTION * Dry ;21 Replacement Well 0 Caved In 0 Pit Well 0 Inactive 0 Test Hole Delected/Suspected Well Water Contaminant(s) Adjacent property with contamination (Address) Known Soil/Water contaminants at adjacent property EXISTING WELL CONSTRUCTION DETAILS 0 Open Bottom 0 Gravel Pack 0 Uncased 0 Other Well Log copy attached 0 Yes tp, No Grout Seal 0 No 0 Yes ft below ground surface (bgs) Hole Diameter inches Well Conductor Casing 0 Yes 170- No Depth of Condror Casing ft bigs_m Diameter of Conductor Casing inches Well Casing Diameter_ c7 inches Total Depth 3o ilV ft Depth to Water/VIM ft Depth of Casing ft bgs DESTRUCTION SPECIFICATION .1 4.• .A Sealing Material from 1,-..,.; ft bgs to L- ft bgs Filler Material 6-'4'4 ' ..-..1. from ,L ,.. ft bgs to J_ C L; ft bgs ._ _ Well casing to be perforated by one of the following methods: from ft bgs to ft bgs _ 0 Mills Knife Number of cuts every ft and/or 0 Explosives 0 Detonating cord 0 with projectiles every _ __ ft 0 without projectile 0 Detonating cord and boosters 0 with projectiles every ft 0 without projectile 0 Other Sealing Material Neat Cement (94 lb bag/5-6 gal water))( Sand Cement l 1,..3 sack mix/7 gal wafer Bentonite Pellets Bentonite (20% solids) Manufacturer Spec % solids % Name Specs on File Specs Submitted Placement Method '54 Pumped Free Fall Other Seal Completion Complete with Mushroom Cap 3 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. 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. Codes SC Info Received By Checke/ Cash Amount Remitted Date WeiriPE llie Permit/ Service Request It Invoice # , Nj k-----'C --f-r. 2'7,-f ' ( 1 N.N•0 lk,F0 1, k - OC,— StZ, Ob 7 j q 0 7 EHLI 43-08 WELL DESTRUCTION PERMIT / N.0 4/30/12