SR0080932 SSNL - Laserfiche WebLink

Home Browse Search

WELL DESTRUCTION PERMIT PUBLIC WATER SYST M ❑Yes ❑No SAN JOAOUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 East Hazelton Avenue-STOCKTON CA 95 05-(209)468.3420 NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR F IOM DATE ISSUED Joe ADDRESS `al 1 Pal "4 i -:Z�4 crTY2iP CROSS STREET APN"-_07-*_2 PARCEL SIZE fi LAND USE APPLICATION p OWNER 7-`lC�'LMhhE'l ,,++ r1AIL_ PHON?S 1101 33 r� i33� OWNER ADDRESSTJ�`,� r U -•i._.,�--'� CITYISTATE/ZIP 7-m CONTRACTOR S ,fl x1 'e 161 1011116v -W. PHONE CONTRACTOR ADDRESS �� 14�,s=rS f,•ITY/STATE2iP U �� Q C-57 WELL DRILLING LICENSE NUMBER bbt� _ EXPIRATION DATE � �•� PERFORATION CONTRACTOR PHONE PERFORATION CONTRACTOR ADDRESS__ CITY/STATE/ZIP ❑ C-57 Weil Drilling License Number Expiratk n Date ❑ Bureau of Alcohol.Tobacco and Firearms-Users of High Explosives License Number - Expiratk n Date ❑ CHP Hazardous Material Transportation for Explosives License Number _ _ Expirati Date ❑ San Joaquin County Sheriff-Coroner[*.xpiosives Application and Permit License Number Expiratic 11 Date ❑ California Occupational Safety Health-Blaster License Number Expirati Date REs5t8d FOR DE$TRUCTKIN D'r'y placement Well ❑ Caved In ❑ Pit Well ❑ Inactive ❑ Test Hale Detected/Suspected Well Water Contaminant(s) Adjacent property with contamination(Address) _ Known Soil/Water contaminants at adjacent property .._........ 90111 ,W,i,CgiiisTRL'CTIoN orlau Open Bottom ❑ Gravel Pack ❑ Uncased ❑ Other ._. ....................__......_.. Well Log copy Attached ❑ Yas No arout Seal ❑ No ❑ Yes,........_.....It below ground surface(b9R) Hole Dialng Or,......_..__...._..._inches Well Conductor Casing❑��hhyes�Q No Depth of Con_0uqjpr Casing ........._f g Diameter of Conductor C*J Ing Inches Well Caaing Diameter .W..... . ..inches Total DePtha .. ft Depth to Weter. .II Depth of Cal ing . __ft bgs DrsTRUCTION SPECT ICAT12 Sealing Material from 5S' ft bgs to _d _ft bgs Filler Material from ..,......_...it b- to _U bgs Well casing to be perforated by one of the following methods: _from _.. .-.. it bgs to. _...- it bgs ❑ MRIs Knife NumGsr of cuts every___ ____.._ft arx9or ❑ Explosives❑ Detonating cord ❑ with projectiles every..,.,__..._._..___.ft ❑ without projectil ❑ Detonating card and boosters ❑ vdth projectiles every_.._.._...... it ❑ without projectil ❑ Other....................__.._.._._____.._..__ _........._._..._._ _..__-_.__......_.,..___.__...._._.__._....___._ _. Seating Material : Neat Cement(94 tb bagIS-6 gal water) Sand Cement.....___....__.__.............._s.nc1(in1x/7 gal water Bentonite Pellets Bentonite(20%solids) Manufacturer Spec%solids._-__...% Name......._.__..___..._....................... Specs on File Specs Submitted Plaent Method Pumped Free Fall Other Seal Completiolt Complete with Mushroom Cap. _7i it bgs Complete to Existing Surface P a I I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN COUNTYJOAQUIN ORDINANCES,STATE Is CURRENT AND ACTIVE WITH THE CALIFORNIAFORNIA CONTRACTORS STATE LICENSE BOARD AND TI HN AT I AM CO N PLICE FY THAT MY REQUIREDICENSE WITH ALL WORKERS COMPENSATION LAWS. ��HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS CONTRACTORS SIGNATURE TITLE &^A^ DATE j AM1 r 1l1tw�A111 SEP RTMENT USE 0 N L /4 J Date- _ Application Accepted By _ .. Area - ' Destruction Inspection By Data__ �.-- �_...._ _.___.__ Employee Op Dlld COMMENTS ___..__....., .._.. PermiUWell ID# PE SC rReceiv�d heck#/- Amount Date 41nvoiceInfo I a:w Cash _ RemilService Request# --• ` 3 70 S W1 LL OES'TRUCTION PERMIT r.rlr>na-oa p '�Z c16 O v E'Y