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WELL DESTRUCTION PERMIT <br /> PUBLIC V 2 SYSTEM [:]Yes ❑No <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 600E MAIN STREET-STOCK,UN CA 95202-(209)468-3420 <br /> NON-REFUNDABLE PERMIT .:x__iZ0' ryo. = 'p!C°E TIONSEXPIRES 1 Y R FROM DATE ISSUED <br /> _v. <br /> JOB ADDRESS CITY/ZIP r+ <br /> Y <br /> APN <br /> CROSS STREET _ PARCEL SIZ LAND USE APPLICATION#� <br /> O <br /> S <br /> OWNER� PHONE � <br /> OWNER ADDRESS CITYISTATE/ZIP <br /> CONTRACTO PHONE ..� <br /> CONTRACTOR ADDRESS CITY/STATE/ZIP <br /> C-57 WELL DRILLING LICENSE UMBIRR 7 EXPIRATION DOTE — <br /> PERFORATION CONTRACTOR. �v PHONE <br /> PERFORATION CONTRACTOR ADDRESS Cm'/STATE171 <br /> IAC-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 II ❑ Caved n ❑ Pit Well 'Inactive ❑ Test HSI_ <br /> Detected/Suspected Well Water Contaminant(s) <br /> AdlMeflt property with contamination(Address) <br /> Known Soil I Water contaminants at adjacent property — <br /> EXISTING WELL CONSTRUCTION DETAILS ❑ Open Bottom ❑ Gravel Pack ❑ Uncased ❑ Other <br /> Well Log copy attached g Yes ❑ No Grout Seal ❑ No If Yes Jr—It below ground surface(bgs) Hole Diameter dV inches <br /> Well Conductor Casing❑ Yes ❑ No Depth of Conductor Casing It bgs Diameter of Conductor Casing inches <br /> Well Casing Diameterinches Total Depth% it Depth to�Water�t fl L Depth ofCasingft bgs <br /> DESTRUCTION SPECIFICATION •� .N !igs <br /> ft b 5 <br /> Sealing Material from ZS ft bgs to ft bgs Ff — gWell casing to be perforated by one of the following methods: from to ft bgs <br /> ❑ Mills Knife Number of cuts every ft and/or <br /> ❑ Explosives❑ Detonating cord ❑ With projectiles every it ❑ without projectile <br /> ❑ Detonating cord and boosters ❑ With projectiles every It ❑ Without projectile <br /> ❑ Other <br /> Sealing Material fkat Cement(94 Ib bag/5-6 gal--t-17) Sand Cement sack mix/7 gal water Bentonite Pellets <br /> Bentonite(20%so _% Name Specs on File Specs Submitted <br /> Placement Method Pumped Free Fall Other <br /> Seal Completion Complete with Mushroom Cap ft 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 /> MINI UW..2 HDUk DVANC= <br /> CONTRACTORS SIGNATURE TiT LF /" DATE <br /> DEPARTMENT USE ONLY (, <br /> Application Accepted By Date 2 Z Area /�- <br /> Destruction Inspection B 9tieq=A <br /> A / Date ( (] Employee ID#- - <br /> COMMENTSL6 6,01J: f6Lo100 /La✓f�G a-�T L`� <br /> PE SC Received Check#/ Amount Date PermlU Invoice# Well ID# <br /> Codes Info By Cash Remitted Service Request# <br /> Oa 60-1 872- (.0" <br /> s z o 8 6 <br /> EHD 43-08 WELL DESTRUCTION PERMIT <br /> 10/5/07 <br />