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WELL DESTRUCTION PERMIT <br /> PUBLIC WATER SYSTEM ❑Yes ❑No <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE 3"O FL-STOCKTON CA 95202 - (209)468-3420 <br /> NON-REFUNDABLE PERNIa CALL(209)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS <br /> yc�,�" CITY/ZIP m <br /> CROSS ET ^ APN O Y / K�O PARCEL SIZE -3LAND USE APPLICATION# <br /> OWNER , Cov � <br /> OWNER ADDRESS CITY/STATE— /ZIP(/J(i(!d /�^�///� <br /> CONTRACTO PHONE0W4cV�7[ J <br /> CONTRACTOR ADDRESS CITY/STATE/ZIP <br /> ' :74e <br /> C-57 WELL DRILLING LICENSE NUMBER EXPIRATION DATE <br /> PERFORATION CONTRACTOR �'%tom PHONE <br /> PERFORATION CONTRACTOR ADDRESS C CITY/STATE/ZIP <br /> -a C-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 Wellaved 1 ❑ Pit W i-- In ctive ❑ Test Hole <br /> Detected/Suspected Well Water Contaminant(s) <br /> Adjacent property with contamination (Address) <br /> Known Soil/Water contaminants at adjacent property <br /> EXISTING WELL CONSTRUCTION DETAILS ❑ Open Bottom ❑ Gravel Pack ❑ Uncased ❑ Other <br /> Well Log copy attached ❑ Yes A No Grout Seal ❑ No ❑ Yes ft below ground surface(bgs) Hole Diameter inches <br /> Well Conductor Casing ❑ Yes 7P No Depth of Conductor Casing ft bgs Diameter of Conductor Casing inches <br /> Well Casing Diameter (� inches Total Depth ft Depth to Water ft Depth of Casing ft bgs <br /> DESTRUCTION SPECIFICATION <br /> Sealing Material from 10 y ft bgs to ft bgs Filler Material tee, �f►AJ 1 ' fromoZ�ft bgs to O0 ft bgs <br /> Well casing to be perforated by one of the following methods: from ft bgs <br /> ❑ Mills Knife Number of cuts every ft and/or <br /> ❑ Explosives ❑ Det ating cord ❑ with p ectiles every ft ❑ without projectile <br /> ❑ Deton ing cord and boosters ❑ with prof tiles every ft ❑ without projectile <br /> ❑ Other <br /> Sealing Material ❑ Neat Cement(94 lb hub/5-6 gal water) ❑ Sand Cement suck mix/7 gal water Bentonite Pellets <br /> ❑ Bentonite(20%solids) ❑ Manufacturer Spec%solids % Name ❑ Specs on File ❑ Specs Submitted <br /> Placement Method ❑ Pumped Free Fall ❑ Other <br /> Seal Completion ❑ Complete with Mushroom Cap ft bgs >iL Complete to Existing Surface Pad <br /> 1 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. 1 ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT 1 AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> MI UM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSP FCTIONS <br /> CONTRACTORS SIGNATURE ;;W--- TITLE DATE <br /> ©fC�yP <br /> PA <br /> �M •Y <br /> �t <br /> SAN Nov <br /> 12019 <br /> OAOUI <br /> a(J <br /> ® Fvr <br /> -. EPARTMENT USE ONLY <br /> Application Accepted By Date r vo� Area <br /> Destruction Inspection By V� Date Employee Ad <br /> COMMENTS C3 U O <br /> PE SC Received heck#/ Amount Date Permit/ Invoice# Well ID# <br /> Codes Info B Remitted Service Request# <br /> 5 iy I w/ <br /> EHD 43-02-008 Well Destruction Permit <br /> 1/27/2005 <br />