SU0012599 - Laserfiche WebLink

Home Browse Search

WELL DESTRUCTION PERMIT PUBLIC WATER SYSTEM D Yes D No SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE 3—FL-STOCKTON CA 95202 -(209)468-3420 NON-REFUNDABLE PERMIT CAIA,(209)953-7697 FOR INSPFCTi(1NS EXPIRES I YEAR FROM DATE ISSUED S. Lt J' t` JOB ADDRESS CITY/ZIP enAn D r v CROSS STREET APN 22-b;�� 7 PARCEL SIZE AND USE APPLICATION# e r •9 z Pxone 3 O OWNER � r. OWNERADDRESS Z S CITYISTATFJZIP CONTRACTOR 1J / f PHONE J "'z - CONTRACTOR ADDRESS / �Y` CITY/STATE/ZIP C-57 WELL DRILLING LICENSENUMBER 7 EXPIRATION DATE PERFORATION CONTRACTOR PHONE PERFORATION CONTRACTOR ADDRESS CITY/STATE/ZIP N ❑ C-57 Well Drilling License Number Expiration Date ❑ Bureau of Alcohol,Tobacco and FITCaMS-Users of High Explosives License Number Expiration Date /^ ❑ CHP Hazardous Material Transportation for Explosives License Number Expiration Date 1 ❑ San Joaquin County Sheriff-Coroner Explosives Application and Permit License Number Expiration Date ❑ California Occupational Safety Health-Blaster License Number Expiration Date h REASON POR DESTRUCTION ❑ Dry ❑ Replacement Well Caved In ❑ "Pit Well ❑ Inactive ❑ Test Hole Detected/Suspected Well Water Contaminant($) Adjacent property with contamination(Address) Known Soil/Water contaminants at adjacent property EmSTING WELL CONSTRUCTION DETAILS ❑ Open Bottom 11�Gravel Pack ❑ Uncased ❑ Other Well Log copy attached ❑ Yes J241No Grout Seal ❑ No ❑ Yes ft below ground surface(bgs) Hole Diameter inches Well Conductor Casing ❑ Yes ❑ No Depth of Conductor Cuing ft bgs Diameter of Conductor Casine inches Well Casing Diameterinches Total Depth�_�ft Depth to Water ft Depth of Casing ft bgs DESTRUCTION SPECIFICATION Sealing Material from ft bgs to ft bgs Filler Material from /OD R bgs to .47' _ft bgs Well easing to be perforated by one of the following methods: from n bgs to ft bgs ❑ Mills Knife Number of cuts every ft and/or ❑ Explosives Cl Detonating cord ❑ with projectiles everyft ❑ without projectile ❑ Detonating cord and boosters ❑ with projectiles everyft ❑ without projectile ❑ Other Sealing Material ❑ Neat Cement(94 lb bag/3-6 gal water) ❑ Sand Cement .rack mix/7 gal water Bentonite Pellets ❑ Bentonite(20%solids) ❑ Manufacturer Spec%solids_% Name ❑ Specs on File Specs Submitted Placement Method 10 Pumped DRIr Free Fall ❑'9th. Seal Completion 41w,Complete with Mushroom Cap - it bgs Complete to Existing Surface Pad 1 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. 1 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. MINIMUM 2f4 HOUR /JADVANCE NOTICE REQUIRED FOR �IIN�SPECTIONS CONTRACTORS SIGNATURE 1/j C' /"t-GGLp�-C!./ TITLE ));, S,l DATE -;;iii�1Ei•.!T OCCOVEL. AUG 3 0 2006 © Puwp SAN JOAOUIN COUNTY 1, ENVIRONMENTAL elHEALTH DEPARTMENT =Vt) -�-8 -TU S-6--O N L Y — ---- ——. � C' Application Accepted By Date V Area Destruction Inspection By s{-1 e I c Date ��e z r Employe COMMENTS i PE Sc Received Cha AmountDate Permif/ Invoke# WellID# Codes Info B Cash Remitted Svi erce R uest# well Dnp—..P-1 EHD 43-02-OON 1/277005 �.