WP0040221 - Laserfiche WebLink

Home Browse Search

WELL DESTRUCTION PERMIT PUBLIC WATER SYSTEM ❑Yes ❑No SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 East Hazelton Avenue-STOCKTON CA 95205 - (209)468-3420 NON-REFUNDABLE /PERMIT / CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS / �/ La[�/�G L'i CITY/ZIP_ f -Job m / � Y CROSS STREET APN_lq/� L70 L 3 PARCEL SIZE/.`i/ LAND USE APPLICATION# "r- z OWNER PHONE rn •r. OWNER ADDRESS '/ / CITY/STATE/ZIP CONTRACTOR E!G _/J�f5Zye./t 7 PHONE -2419 - CONTRACTOR ADDRESS CITY/STATE/ZIP LOC �1t 7 J Z y/ C-57 WELL DRILLING LICENSE NUMBER k� EXPIRATION DATE 262-g:> 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 &6 Inactive ❑ Test Hole Detected/Suspected Well Water Contaminant(s) Adjacent property with contamination (Address) Known Soil/Water 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 bgs Diameter of Conductor Casing inches Well Casing Diameter _inches Total Depth '070_ It Depth to Water_ It Depth of Casing It bgs DESTRUCTION SPECIFICATION Sealing Material from 1110 ft bgs to --57 - ft bgs Filler Material 71"_from ft bgs to ft bgs Well casing to be perforated by one of the following methods: from _ - ft bgs to ft bgs ❑ Mills Knife Number of cuts every ft and/or_—_ _ ❑ Explosives ❑ Detonating cord ❑ with projectiles every ft ❑ without projectile ❑ Detonating cord and boosters ❑ with projectiles every ft ❑ without projectile ❑ Other _ Sealing Material Neat Cement(94 lb bag/5-6 gal water) Sand Cement sack mix/1 gal water Bentonite Pellets Bentonite(20%solids) I Manufacturer Spec%solids o Name Specs on File Specs Submitted Placement Method Y Pumped i i Free Fall Other Seal CompletionD< Complete with Mushroom Cap ' r� ft bgs CI 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. yb MI IMUM 94 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS CONTRACTORS SIGNATURE /i TITLE !!//Sro[-AA DATE .._.... _...__.._... .._ _._. r . _ _ _ _._. _ _ SpN JOS _ .. _.,...__.._....._ '1 _.._.....__._... _...__....._...._._.. ......_.... _-.._._.._ .._.........__.... ...- -""-"- "- --" SIR 4 M �U NEq T/H p N i FNTgL _ EPARTII�R Nr 4+1 DEP-ARTMENT USE ONLY Application Accepted By ` _ _ _ _ _ __ _ Date a _2-5 Area t`v Destruction Inspection By _ _ —t_ — Date L Employee I n �— r-- COMMENTS C^1 t d� Wta � PE SC Received Check#/ Amount D to Permw Invoice# Well ID# Codes Info Cash Remitted Servfa�RegIIest'# E' EHD 43-08 WELL DESTRUCTION PERMIT 7Q` 4/30/12 /O