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WELL DESTRUCTION PERMIT <br /> PUBLIC .R SYSTEM ❑Yes B-No <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 600 E MAIN STREET-STOCKTON CA 95202 -(209)468-3420 <br /> NON-REFUNDABLE PERMIT C- ! '—(209)953-7697 FOR INSPECTIONS EXP R S 1 YEAR FROM DATE ISSUED <br /> i <br /> JOB ADDRESS CITY/ZIP m <br /> Y <br /> CROSS STRE APN PARCEL St AND USE P LICATION# <br /> C <br /> z <br /> OWNER PHONE <br /> OWNER ADDRESS CITY/STATE/ <br /> CONTRACTOR PHONE L" <br /> CONTRACTOR ADDRESS CITY/STATE/ZIP <br /> C-57 WELL DRILLING LiCEN E OUMBER EXPIRATIO E <br /> PERFORATION CONTRACTOR PHONE <br /> PERFORATION CONTRACTOR ADDRESS CITY/STATE/ZIP <br /> BSC-57 Well Drilling License Number Expiration Date <br /> Bureau of Alcohol,Tobacco and Firearms-Users of High Explosives License Number Expiration Date <br /> CHP Hazardous Material Transportation for Explosives License Number Expiration Date <br /> San Joaquin County Sheriff-Coroner Explosives Application and Permit License Number Expiration Date <br /> California Occupational Safety Health-Blaster License Number Expiration Date <br /> REASON FOR DESTRUCTION ❑ Dry ❑ Replacement Vvell Caved In ❑ Pit Well pr In ctive ❑ Te Hole <br /> Detected/Suspected Well Water Contaminant(s) 2 <br /> A4490mt property with contamination(Address) <br /> Known Soil/Water contaminants at adjacent property_ _ <br /> EXISTING WELL CONSTRUCTION DETAILS ❑ Open Bottom ❑ rGrravel Pack ❑ UncaSed ❑ Other <br /> Well Log copy attached a� Yes ❑ No Grout Seal ❑ No 19 V 1%below ground surface(bgs) Hole Diameter _inches <br /> Well Conductor Casing❑ Yes J6 No Depth of Conductor C sing ���Lii ft bgs Diameter of Conductor Casing inches <br /> Well Casing Diameter__inches Total Depth Conductor <br /> Depth to Water fl Depth of Casing _ft bgs <br /> DESTRUCTION 51'k('IFICATION bl..AAI o <br /> Sealing Material from � ft bgs to�� DLW.A - "rO ' is <br /> Well casing to be perforated by one of the following methods: from ft bgs to It bgs <br /> ❑ Mills Knife Number of cuts every ft and/or <br /> ❑ Explosives ❑ Detonating cord ❑ with projectiles every ft ❑ without projectile <br /> ❑ Detonating cord and boosters ❑ with projectiles every ft ❑ without projectile <br /> ❑ Other <br /> Sealing Material eat Cement(94 Ib bag/5-6 gal wafer Sand Cement sack mix/7 gal water Bentonite Pellets <br /> Bentonite(20%solids anu pe s % Name Specs on File Specs Submitted <br /> Placement Method Pumped Free Fall Other <br /> Seal Completion Complete with Mushroom Cap It bgs Complete to Existing Surface Pad <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> I IMUI)4'2 HOUR DUAN NOTICE REQUIREDFORINSPEC 104 C <br /> CONTRACTORS SIGNATURE TITLE A' DATE <br /> DEPARTMENT USE ONLY <br /> Application Accepted By _ Date <br /> §72 Area > 7 7 <br /> Destruction Inspection By14 Date D Employee ID# <br /> COMMENTS L& rT6 _ �tl�Q ( CC—� �Q� �Cj•bO <br /> PE SC Received Check#/ Amount Date Permit/ Invoice# Well ID# <br /> Codes Info 8 Cash Remitted Service Request# <br /> I:V702 60- 14 <br /> EHD 43.08 WELL DESTRUCTION PERMIT <br /> 10/5/07 <br />