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WELL DESTRUCTION PERMIT PUBLIC WATER SYSTEM ❑Yes*o SAN JOAOUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 East Hazelton Avenue-STOCKTON CA 95205 - (209))468-3420 NON-REFUNDABLE/PERMIT y� CALL 209 953-7697 FOR INSPECTIONS �EXPIRES 1 YEAR FRR-O•M DATE ISSUED JOB ADDRESS �G' � G'� CITY/ZIP r— Y CROSS STREET N. � S r APN PARCEL SIZE�4' iANND USE APPLICATION# OWNER PHONE OWNER ADDRESS f(� 7 .0 � CITY/STATE/ZIP CONTRACTOR VM e �l ,mss' PHONE �/ CONTRACTOR ADDRESS � �e_7 Z) f E y l CITY/STATE/ZIP J C-57 WELL DRILLING LICENSE NUMBERiitJ,jl� EXPIRATION DATE ' I- 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 ❑ 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 ravel 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 t Diameter of Conductor Casing inches Well Casing Diameter_inches Total Depth _�j 5 X1t- Depth to Water, _ Depth of Casing _ft bgs DESTRUCTION SPECIFICATION Sealing Material from ____ ft bgs to ft bgs Filler Material__ 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 It and/or El Explosives ❑ Detonating cord ❑ with projectiles every ft ❑ without projectile ❑ Detonating cord and boosters ❑ with projectiles every It ❑ without projectile ❑ Other Sealing Material Neat Cement(94 lb bag/5-6 gal water) Sand Cement sack mix17 gal water er Bentonite Pellets C Bentonite(20%solids) Manufacturer Spec%solids _% Name Specs on File Specs Submitted Placement Method PumpedFree Fall F1 Other Seal Completion Complete with Mushroom Cap _ft bgs )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. _ ADVANCE NOTICE REQUIRED FOR INSPECTIONS A y CONTRACTORS SIGNATURE L T l�l %'i/i�7�,-- TITLE L�/G %� DATE04 i.._ . .. j t ._......__ .. .._._...... .................. -...........-- ...._.................. .. .. .... .............................. . ..� ._.. ..�.., �p .. -- -- Jbq opt ENVI QUIN CO RO N { _�....__..._.... __.... _ ._.._.__..... -- .._....... _......_......._.... ..__...._.............._ — LT — H p pgRENrl' DEPA.RT'MENT USE ONLY Application Accepted By Date v Area Destruction Inspection By Ut: Date L' Employee 6# COMMENTS (.NLkL J ------------ �VJ PE Sc Received —Amount DatePermit/ Invoice# Well ID# Codes Info Cash Remitted t# EHD 43-08 WELL DESTRUCTION PERMIT 4/30/12