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WELL DESTRUCTION PERMIT " PUBLIC WATER SYSTEM ❑Yes ❑No SAN JOAQUIN 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 YEAR FROM DATE ISSUED JOB ADDRESS r /L� / CITY/ZIP % -7�t) r CROSS STREET Jz L• Q A P N �L/S V� %�� —� _ PARCEL SizEE�� LANNDDD USE APPLICATIIOONN## OWNER `• _ / /L — /w PHONE OWNER ADDRESS �' CITY/STATE/ZIP L%7Z 7Z � CONTRACTOR f ( A /C t PHONE C L- ) CONTRACTOR ADDRESS ��/� `'L��L�j��/ �� CITY/STATE/ZIP � 7 �/ C-57 WELL DRILLING LICENSE NUMBER /-:?/7' EXPIRATION DATE PERFORATION CONTRACTOR PHONE E PERFORATION CONTRACTOR ADDRESS CITY/STATE/ZIP I!/ ❑ C-57 Well Drilling License Number Expiration D4 j ❑ Bureau of Alcohol,Tobacco and Firearms-Users of High Explosives License Number Expirati'§A ate ❑ CHP Hazardous Material Transportation for Explosives License Number Expiration�k AQU_ IIy rr,,,,, ❑ San Joaquin County Sheriff-Coroner Explosives Application and Permit License Number ExpiratiRONMr F'q�E'N�T��'v O California Occupational Safety Health-Blaster License Number Expiration Date ""rtN REASON FOR DESTRUCTION ❑ Dry ❑ Replacement Well ❑ Caved In ❑ Pit Well Inactive ❑ Test Hole Detected/Suspected Well Water Contaminant(s) 4&A,�fl/1-e, 7r-, Adjacent property with contamination (Address) C—J T-4- 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 Jt bgs Diameter of Conductor Casing_ _ inches Well Casing Diameter__ _inches Total Depth _ J4� Depth to Water__ ft Depth of Casing _.ft bgs DESTRUCTION SPECIFICATION Sealing Material from _ ft bgs to It bgs Filler Material_ _ from ft bgs to It 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 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 gat water) Sand Cement sack mix/7 gal water 7 Bentonite Pellets Bentonite(20%solids) Manufacturer Spec%solids _ % Name _ Specs on Fil Specs Submitted Placement Method Pumped Free Fall Other Seal Completion Complete with Mushroom Cap /�2 ft bgs ( _ Corpp�Q �g Existing Surface Pad I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND fHAT 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. Y8 M UM / D7V�ANNCE NOTICE REQUIRED FOR INSPECTIONS CONTRACTORS SIGNATURE 'S !' /�'�/?imp/ 1�7 TITLE DATE 3 I, f ...... --- - -- ................ ' C r D E P A R T M E N T US EO Y Application Accepted By _ _ Date Area 1 Destruction Inspection By _ Date Z It fIr Employee ID COMMENTS IL' VV )' Ga� Sea PE SC Received hec Amount Permit/ Codes Info Bv UashRemitted Date Service Request# Invoice# Well ID# d4XSq i�A u c - EHD 43-08 WELL DESTRUCTION PERMIT 4/30/12