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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 CALL 2O9 95 -7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED �n JOB ADDRESS c!3 /� /-� G,�! /f�f��.CITY21P C CROSS Sj,QEF,T /Q 0 APN `O9 7`SVM PARCEL SIZE_LAND U�SEE APPPLICATIOONN# .p 0 OWNER JV�/I/ 1, r �7 PHONE OWNER ADDRESS kJAl ACE • 1$ % a CITY/STATE/ZIP CONTRACTOR t 4PHONE 7&S -491-1260 n CONTRACTOR ADDRESS II! CITY/STATE/ZIP r s Le-57 WELL DRILLING LICENSE NUMBER EXPIRATION DATE 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 ❑ Dry ❑ Replacement Well 2r-Caved In ❑ Pit Well 0.-N�active ❑ 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 &-15-ravel Pack ❑ Uncased ❑ Other Well Log copy attached ❑ Yes 0—No Grout Seal ❑ No ❑ Yes ft below ground surface(bgs) Hole Diameter inches Well Conductor Casing❑ Yes C;--No Depth of Conductor Casing ft bgs Diameter of Conductor Casing inches Well Casing Diameter_1:�inches Total Depth ft Depth to Water ft Depth of Casing� ft bgs DESTROCTION SPECIFICATION /+x�A,A�1.1 Sealing Material from _I y� ft bgs to C ft bgs Filler Material. from t bgs to_. _ft bgs Well casing to be perforated by one of the following methods: from ft bgs to ft bgs PA y` ❑ Mills Knife Number of cuts every ft and/or 14, ❑ Explosives❑ Detonating cord ❑ with projectiles every ft ❑ without projectile ^/ Ir ❑ Detonating cord and boosters ❑ with projectiles every ft ❑ without projectile C veb ❑ Other Sealing aterial Neat Cement(94/b bag/5-6 gal water) Sand Cement sack mix/7 gal water Bentonite Pellet—.MA( ry 411 entonite(20%solids) Manufacturer Spec%solids_% Name Specs on File Specs ISub%itted C ?O?0 Placement Method Pumped Free F-II Other ''A/�l J Seal Completion Complete with Mushroom Cap--I,—ft bgs Complete to Existing Surface Pad EN AQUM ry I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH /p p ENT,q� JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS gR'r4f NT CURRENT AND ACTIVE WITH HE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL WORKERS COMPENSATIONS. r R ADVANCE NOTICE REQUIRED FOR �IINNSjPV—DATE/— S CONTRACTORS SIGNATURE TITL( J{{///s/C 2 2_Zo j t f _:-.........—._-_...:_. _ _ . . � f ........... * � Q S +- r ! , , -.t 1 i 1 j , I ! , t .....i i i PA TMENT USE ONLY Application Accepted By Date t 4? �D�O Area �V Destruction Insp ction Date 1 2 7 1" Employee ID# COMMENTS led—Z in 7 JeJt , WJ PEA4;ceived Check#/ Amount4Date Permit/ Invoice# Well ID# Codes Cas RemittedService Request# 3 EHD 43-08 WELL DESTRUCTION PERMIT revised 4114118 4W- /031q /--yy/L��