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WELL DESTRUCTION PERMIT PUBIC WATER SYSTEM [-]Yes ❑No SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPT 1868 East Hazelton Avenue-STOCKTON CA 95205-6232 -(209)468-3420 NON-REFUNDABLE PERMIT �y CALL 09 9 3-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED JOSS B ADDRESS /h C It If ee��..�.�L E' CITY/ZIP e�YC o S ?cU CRO. ROST Q'A �APN K 7-51,>-C�Zo PARCEL Siza�LAND SE APPLICATION# o OWNER r Jt S/' r PHONE D -/-d��j �j 5y��J 7 6O e OWNER ADDRESS /1" G vC_ -CITY/STATE/ZIP CJ"C// GL A, 7 2 6 CONTRACTOR Q !' r PHONE 0 o IVit- CONTRACTOR �r� CONTRACTOR ADDRESS B ✓• , g CIN/STATE2IP Z4 Q ,0Q 1 7 I- /,3, j O`er �-C-57 WELL DRILLING LICENSE NUMBER 5 V --/2-/ EXPIRATION DATE 5 r�3 A 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 I_'r7r-y ❑ Replacement Well ❑ Caved In ❑ Pit Well ❑ 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 Q Gravel Pack ❑ Uncased ❑ Other Well Log copy attached ❑ Yes @?Mo Grout Seal ❑ No iM'Yes ft below ground surface(bgs) Hole Diameter-a-A*inches Well Conductor Casing❑ Yes AT-No Depth of Conductor Casing ft bgs Diameter of Conductor Casing inches Well Casing Diameter 6•• inches Total Depth _ft Depth to Water ft Depth of Casing 4-d- ft bgs DESTRUCTION SPECIFICATION {/� 1 Sealing Material from ?b ft bgs to ft bgs Filler Material 6ee•GYl r T G from JgP�--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 A41, �� ❑ Detonating cord and boosters ❑ with projectiles every ft ❑ without projectile ❑ Other CO Sealing Material Neat Cement(94 Ib bag/5-6 gal water) Sand Cement sack mix/?gal water Bentonite Pellets Bentonite(20%solids) Manufacturer Spec%solids_% Name Specs on Fife Specs Submitted Placement Method Pumped Free Fall f Other SO Al 1Q Seal Completion Complete with Mushroom Cap ft bgs Complete to Existing Surface Pad O50 I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAI"THE WORK WILL BE DONE IN ACCORDANCE WITH SA L H O )Mj 014 JOAQUIN CURRENT ANDNTY ACTIIVE ORDINANCES, WIITH THESTATE LAWS, AND RULES CAL CALIFORNIA CONTRACTORS NSTATEU LICENSE BOARD AND CERTIFY HAT I AM IN CO PLIANCE LICENSE ALL �FpgR M H WORKERS COMPENSATION LAWS. MI fMUM 48 HOLW ADVANCE NOTICE REQUIRED FOR INSPECTION,F, CONTRACTORS SIGNATURE TITLE X/_A DATE Ilk k 6n 6" 1 � J df ells L I off We 0 V DEPARTMENT USE ON G� Application Accepted By IF Dale �J Area Destruction Inspecti n By Da d Emplo ID# ENTS / COMMG � j z� t ' 1,Ai e 11 F'1 If 11, LN i 0 IV t L X PE SC Received he Amount Permit/ W l D to Invoice# Well ID# L Codes Info Cash Remitted Service Re uest# 'PO6 q 017 6�Jz��l`I EHD 43-08 WELL DESTRUCTION PERMIT revised 4/14/18