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'r , d �j WELL DESTRUCTION PERMIT w(�O� -(��/ PUBLIC WATER SYSTEM ❑Yns1p SAN JOAOUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1068 East Hazelton Avenue-STOCKTON CA 95205 - (209)468-3420 NON-REFUNDABLE PERMIT CALL 209 99553-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS L- ( L _J CITY/ZIP CROSS STREET /!(., APN .�75�/�l ��PARCEL SIZE LAND USE APPLICATION k _ C OWNER �1�/'�S PHONE � OWNER ADDRESS l ! J CITY/STATE(ZIP CONTRACTOR �.' 1 ZC HONE CONTRACTOR ADDRESS CITY/STATE/ZIP ❑ C-57 WELL DRILLING LICENSE NUMBER 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 "ry Replacement Well ❑ Caved In ❑ Pit Well ❑ Inactive ❑ Test Hole Detected/Suspected Well Water Contaminant(s) Adjacent property with contamination(Address) Known SoilANater contaminants at adjacent property EXISTING WELL CONSTRUCTION DETAILS ❑ Open Bottom ❑ Gravel Pack ❑ Uncased ❑ Other Well Log copy attached ❑ Yes ❑ No Grout Seal ❑ No ❑ Yes It below ground surface(bgs) Hole Diameter - Inches Well Conductor Casing ❑ Yes ❑ No Depth of Conductor Casing_. _ it b,s Diameter of Conductor Casing inches Well Casing Diameter � .inches Total Depth 7�Jtlt Depth to Water � �it Depth of Casing ..,_ _ It bels DESTRUCTION SPECIFICATION Sealing Material Irnm It hds to It bgs Filler Material ___from __ ft bgs to _it bgs Well casing lobe perforated by one of the following methods: __._ from _ __ ft bgs to It bgs ❑ Mills Knife -- of cuts every it and/or---, ❑ Explosives ❑ Detonating cord ❑ With projectiles every ft ❑ without projectile ❑ Detonating cord arid boosters ❑ with projectiles every it ❑ without projectile ❑ Other - ----- Sealing Material Neat Cement (94 Ib bag"5-6 gat water) Sand Cement sack rnix/7 gal water Bentonite Pellets Bentonite(20'0 solids) Manufacturer Spec%solids _ ".o Name Specs on Fife Specs Submitted Placement Method ,XJ ' Pumped Free Fall f Other Seal Completion Complete with Mushroom Cap t trgs 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. 24 , QWR ADVANCE NOTICE REQUIRED FOR INSPECTIONS CONTRACTORS SIGNATURE `s V TITLE / �G� _ /L fir— DATE ! 1 i - _ Ud 11 d+[—. —1 — -�- r•✓ t -- QG Application Accepted By Date Area Destruction Inspection B Date y r Employed IDh pQA4rl — COMMENTS / a PE SC Received •.Checks/_ ' Amount PermlIV �i r i— e p Date Invoice i �r We C des Info By CtT9fi Remitted Service Request N G �z� y Z I �4 Is o �frq f ��ti EHD43-08 WELL.DESTRUCTION PERMIT 4/30/12