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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 ;ALU(209)953-7697 FOR INSPECT;—.\s pA EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS �•C� 6 ' CITY/Zip_ 41 pf CROSS ST ET IP f O, APN 2D 4 Y L C>27 PARCEL SIZE_LAND USE APPLICATION# OWNER R a r 3' �, PHONE 1-6-10 r (+ p yb OWNER ADDRESS CC / rr Scb CITY/STATE/ZIP &r;vcR C(y e5l.2I17 2 CONTRACTOR C' HiQ �y /yam G. 765-- y,2 n �+ PHONE � T L p CONTRACTOR ADDRESS.3pO. S. l�Ir/ my / !/ CITY/STATERIPn_((��Q OG/\ L/Q f 1,J 80 C-57 WELL DRILLING LICENSE NUMBER 7�,7 7 2 If EXPIRATION DATE 5-3 PERFORATION CONTRACTOR PHONE PERFORATION CONTRACTOR ADDRESS CITYISTATE/ZIP ❑ C-57 Well Drilling License Number Expiration Date CL+I��Mi�T Bureau of Alcohol,Tobacco and Firearms-Users of High Explosives License Number Expiration Date C CHP Hazardous Material Transportation for Explosives License Number Expiration Date San Joaquin County Sheriff-Qoroner Explosives Application and Permit License Number Expiration Date 22 2020 California Occupational Safety Health-Blaster License Number Expiration Date REASON FOR DESTRUCTION ❑ Dry ❑ Replacement Well ❑ Caved In ❑ Pit Well naotive ❑ Test Hq NV(?ON CQtJN Detected/Suspected Well Water Contaminants) t fEALT NMSNTAL �Y Adjacent property with contamination(Address) 4EPARTMENT 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❑ Yes No Depth of Conductor Casing ft bgs Diameter of Conductor Casing inches Well Casing Diameter inches Total Depth ft Depth to Water ft Depth of Casing��ft bgs DESTRUCTIO\SPECTFICATInN Sealing Material from VI ft bgs to_(t) ft bgs Filler Material_ from R bgs to_ ft bgs Well casing to be perforated by one of the following methods: from ft bgs to ft bgs 11Mills Knife Number of cuts every ft and/or ❑ Explosives❑ Detonating cord ❑ with projectiles every ft ❑ without projectile ❑ Other ❑ Detonating cord and boosters ❑ with projectiles every ft ❑ without projectile Sealing Material Neat Cement(94 to bag/5-6 gal water) Sand Cement sack mix/7 gal water Bentonite Pellets ✓Bentonite(20%solids) Manufacturer Spec%solids_% Name Specs on File Specs Submitted Placement Method .-Pumped Free Fall Other I Seal Completion Complete with Mushroom Cap / It bgs Complete to Existing Surface Pad I 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 ACTIVzRi RACTORS STATE LICENSE BOARD AND THAT 1 AM IN COMPLIANCE WITH ALL WORKERS COMPENS ANCE NOTICE REQUIRED FOR INSPECT O� CONTRACTORS SIGNATURE TITLE Q DATE �� 2 2-2Qr ......._l n ,eSI�4 Ve 2 m S ..y..... ._.._._... >._.._- � 1 __w_.L a.__._..._..__.._L._...... ......_., j _ # �. i......._....d........ $..._ It ..� ��_.. _... ._.... _ .. f._... .. y o } r 5/' � t I -t �..._.. I ........_................... A j I EPARTMENT USE ONLY Application Accepted By Date 2 Area Destruction Inspection By, '!° I' Date 2-' ZL' Emplo ee ID# COMMENTS—F4 r, y+Jv is PE SC Received Check#/ Amount J Permit/ Codes In Cas Remitted Date Service Re u st# Invoice# Well ID#