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WELL DESTRUCTION PERMIT PUBLIC WATER SYSTEM ❑Yes ❑No SAN JOAOUIN COUNTY ENVIRONMENTAL HEALTH DEPARTNIENT 1868 East Hazelton Avenue-STOCKTON CA 95205 - (209)468-3420 NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPI ES 1 YEAR FROM DATE ISSUED JOB ADDRESS / 9 9,0 G dwr2 Ear 2 a A 1En c CITY/ZIP S oC O K 04 CROSS S REET APN O S� /��D5 Z PARCEL SIZE, r AND USE APPLICATION# OWNERPCkA—Y�, 1�t d, Ike �' Ag PHONE /OC/�/GKGP l/� /V 237 OWNER ADDRESS O, 67 -L/ 3 CITY/STATE2IP7P-1 G/4 oc r CONTRACTOR H ` .%I PHONE 20 ,7 - 7 S- CO e-1 �+ /, CONTRACTOR ADDRESS-CooH. p CITY/STATE/ZIP M— C-57 WELL DRILLING LICENSE NUMBER d�3 y� / EXPIRATION DATE PERFORATION CONTRACTOR_C,as C © PHONE /` S-30 '/i/G4,- 17 /6 PERFORATION CONTRACTOR ADDRESS, -P(� (J d x 7/ d CITY/STATE/ZIPWCoaG/�-".. Com_9s27cp [9K C-57 Well Drilling License Number -IJ?V.?7�Y' Ex iration D to s 31-•Z� W' Bureau of Alcohol,Tobacco and Firearms- Users of High Explosives License Number 9�-IQ V-OA Exirationate l 9-_ J"20 V'-CHP Hazardous Material Transportation for Explosives License Number /` 7 (p/7 Expiration Date 9-31-2 Rd� San Joaquin County Sheriff-Coroner Explosives Application and Permit License Number C043(o S 2? Expiration Date/D C�California Occupational Safety Health-Blaster License Number I Expiration Date •? -/ REASON FOR DESTRUCTION ❑ Dry ❑ Replacement Well ❑ Caved In ❑ Pit Well Z�- hactive ❑ 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 fld�Gravel Pack ❑ Uncased ❑ Other Well Log copy attached ❑ Yes 11"'No Grout Seal ❑ No ❑ Yes _ft below ground surface(bgs) Hole Diameter __ inches Well Conductor Casing ❑ Yes ❑ No Depth of Conductor Casing ft bgs Diameter of Conductor Casing inches Well Casing Diameter _ -1N inches Total Depth 7 Y It Depth to Water_ _y_p _ ft Depth of Casing _ _ft bgs DESTRUCTION SPECIFICATION Sealing Material from ' ft bgs to p 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 /O ft bgs ❑ Mills Knife --- Number of cuts every _ft and/or.__...._ _ 2.1 a6- Q IA?-,J I9/Explosives ❑ Detonating cord ❑ with projectiles every /D ft ❑ without projectile CAP 11,* t- ❑ eton ting cord and boo iers ❑ with projectiles every ��ft ❑ without projectile e� , ❑ other_ iw B�'V-[_,Th"AR_;}c_Va G itAj',N _ Sealing Materiae CemeAt(94 lb bag -6 gal water) ✓hand Cement �D.3 sack/77ix/7 gal water Bentonite Pellets Bentonite(20%solids) Manufacturer Spec%solids_ % Name Specs on File Specs Submitted Placement Method ✓ Pumped Free Fall `1 Other Seal Completion t/+Complete with Mushroom Cap a7 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. 18 MI MUM HOUR AEIVANCE NOTICE REQUIRED FOR INSPEC ON CONTRACTORS SIGNATURE TITLE DATE _ i I i o _1--T+T- ll Q _ 4t . ...... vJ� j O t .. _ _ _..t.. a 7 f. J-1.4/ _._.... .. -......._.. f 2. )- F QL W CS r C-rAT4Q y 941 ____�.___4___ _ DEPARTMENT USE ONL Application Accepted By _ Date h6Area 1 Destruction Inspection By Date Employee IDI COMMENTSi / PE Sc Received Check#/ Amount Date Permit/ Invoice# Well ID# Codes Info B as Remitted Service Re uest# EHD 43-08 WELL DESTRUCTION PERMIT 4/30/12