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WELL DESTRUCTION PERMIT PUBLIC WATER SYSTEM ❑Yes ❑No P SAN JOAOUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 East Hazelton Avenue-STOCKTON CA 95205 - (209)468-3420 NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YE/AR�/FROM DATE ISSUED JOB ADDRESS 1'70-05 CITY/ZIP CROSS STREET A P N PARCEL SIZE AND USE APPLICATION# OWNER i0orl, �QPHONE A �7 r OWNER ADDRESS Pd p(�( ( SL CITY/STATE/ZIP r CONTRACTOR PHONE 33&1�- ySL3 CONTRACTOR ADDRESS P-6 �e� �6 0 CITY/STATE/ZIP Q�C-57 WELL DRILLING LICENSE NUMBER S�Z 3 EXPIRATION DATE--76 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 XDry ❑ 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 It below ground surface(bgs) Hole Diameter— inches Well Conductor Casing ❑ Yes ❑ No Depth of Conductor Casing __ It bgs Diameter of Conductor Casing_ inches Well Casing Diameter__inches Total Depth J Cf O It Depth to Water_ f_ U -ft Depth of Casing ft bgs -- 9 DESTRUCTION SPECIFICATION Sealing Material from /yo 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 - It bgs ❑ Mills Knife __ __._.-Number of cuts every_.____.._____ft and/or El Explosives Explosives ❑ Detonating cord ❑ with projectiles every ft ❑ without projectile ❑ Detonating cord and boosters ❑ with projectiles every ft ❑ without projectile ❑ Other Sealing Material Neat Cement(94 lb bag/5-6 gal water)-7 Sand Cement sack mix/7 gal water Bentonite Pellets Bentonite(20%solids) Manufacturer Spec%solids % Name Specs on File Specs Submitted Placement Method Pumped i Free Fall Other Seal Completion OC-.,Complete with Mushroom Cap ?� It 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. Yg MI�VIMU HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS CONTRACTORS SIGNATURE - TITLE �fBff/w✓ DATE �1�Z5-f7 t if _........�...................,.... _._.... ....._.................__,...W .............. ._. .�..�... .. .. _ _... ... ... ... ,. - _ i _......... __. _ ..............-....._._..__...__.._..__._. ___. .__.._.. ,__......_L._..__........._.....__.........._........._..........._._. ._.................._..-. _.._....................._............_. _..... ._ ... - -.__ _..... ._ .. _ _._... l ...... .. ._._ -f .....-.... -- _... ; .._......................_........- -- - ..�.__-_.........._.. ._.._.._... - ---- - - - _ - _......................... .. ......_.......`.................. EP RTMENT USE ON Y Application Accepted By / e _ Date Area _ Destruction Inspection By ��'7Tk _ Date /y/Z—/r r Employee ID# COMMENTSL L�I�/ `_ u�✓r �i i� �S'�y ICO 7tirt d � '! c'• 10-3 PE Sc Received Amount Date Permit/ Invoice# Well ID# Codes Info B Cash Remitted Service Request# EHD 43-08 /� ti /L I D ��j �fl WELL DESTRUCTION PERMIT 4/30/12 �l"l/�/'{— Il T ✓J