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WELL DESTRUCTION PERMIT PUBLIC WATER SYSTEM ❑Yes ❑No SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPT 1868 East Hazelton Avenue-STOCKTON CA 95205-6232-(209)468-3420 NON-REFUNDABLE PERMIT CALL 209 953-7697 OR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED lur ur JOB ADDRESS C CITY/ZIP I a CROSS STREET o �/� ` APN PARCEL SIZELAND US APPLICATION# d OWNER (M �1 PHON o OWNER ADDRESS L 1-"1 1<- '^ CITY/STATE/IJ-A. Z-IPI / C'(f�' CONTRACTOR ,L L St l/t PHONE V 1.61 CONTRACTOR ADDRESS CIN/STATE/ZIP C-57 WELL DRILLING LICENSE NUMBER ��-1 EXPIRATION DATE C --2-L-) PERFORATION CONTRACTOR PHONE PERFORATION CONTRACTOR ADDRESS CITY/STATE/ZIP 7 C-57 Well Drilling License Number V 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 ❑ Gravel Pack ❑ Uncased ❑ Other Well Log copy attached ❑ Yes ❑ No Grout Seal ❑ No ❑ Yes ft below ground surface(bgs) Hole Diameter inches Well Conductor Casing T Yes ❑ No Depth of Co dor Casing ft bgs Diameter of Conductor Casing inches Well Casing Diameter inches Total Depth It Depth to Water _ft Depth of Casing It bgs DESTRUCTION SPECIFICATION Sealing Material from ft bgs to [10 0 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 ft and/or ❑ Explosives❑ Detonating cord ❑ with projectiles every It ❑ without projectile ❑ Detonating cord and boosters ❑ with projectiles every ft ❑ without projectile ❑ Other S ent(94 lb bag/5-6 gal wafer) Sand Cement sack mix/7 gal water Bentonite Pellets o s_% Name Specs on File Specs Submitted Placement od Pumped Free F Other Seal Completion Complee eMus hroom 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. ( 1I? 4 OUR AN OTICE REQUIR FOR $l1PECTI NS CONTRACTORS SIGNATURE TIRE ` DATE I 12-Lo _.............._........._........... _.._._ .__.�_ _...._..._.._.__ .. _................-.......-- -- _ _ ._._. _._.. ...._..+�._....,._._.i._ .... _. MENT EIVED _..._.. ..:_............ _ ! AQUIN COUNTY IRONMENTAL H D E-PARTMENT i - I i I I _.__ -I ! --..._...__..._.._...__ ._.............._. . _......__..1..__ ._..._._i44-- IIL itA MENT USE ON Y // Application Accepted By Date C Area Destruction Inspection By Date 2 Employee ID# COMMENTS PE Sc Received Check#/ Amount Permit/ Codes Info Cash Remitted ate Service Re uest# Invoice# WeIIID# 1 n EHD 43-08 WELL DESTRUCTION PERMIT 10/5107