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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(2091 953-7697 IOP,iNSPcCT!ONS EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS 41 O® _ Y 9/T!-2� / C � ITY2IP__7`�AC 7 J -� m CROSS S EET Q APN AO 4- `T 6.0� PARCEL SIZE_LAND USE APPLICATION# C OWNER /r J 4. / PHONE �� 6 I /e� y OWNER ADDRESSr-E S ' y / CITYISTATE2IP_��/f✓tR "� �OZQ 2 CONTRACTO Q /rtl /q O, PHONE—21:5f- -r- CONTRACTOR -CONTRACTOR ADDRESS S- IC.gi .7 tJ Q Q CITY/STATE/ZIP TLeg /'� �Cr57 WELL DRILLING LICENSE NUMBER `/ 3 y 2 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 —4.0California Occupational Safety Health-Blaster License Number Expiration Date A/ REASON FOR DESTRUCTION ❑ Dry ❑ Replacement Well ❑ Caved In ❑ Pit Well &;-4nactive 'r ❑ Test Hole Detected/Suspected Well Water Contaminant(s) 020 Adjacent property with contamination(Address) VIRON)N MEIVOOV7) Known Soil/Water contaminants at adjacent prope ty EXISTING WELL CONSTRUCTION DETAILS ❑ Open Bottom Gravel Pack ❑ Uncased ❑ Other Well Log copy attached ❑ Yes 2-No Grout Seal ❑ No ❑ Yes ft below ground surface(bgs) Hole Diameter �/ inches Well Conductor Casing❑ Yes 1/No Depth of Conductor Casing ft bgs Diameter of Conductor Casing inches Well Casing Diameter_inches Total Depth_Z_2_ft Depth to Water ft Depth of Casing J0 ft bgs 9 DESTRUCTIONSPECIFICATION ^ SealingMaterial from ' �� (_:ft bgs to d 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 ❑ Mills Knife Number of cuts every ft and/or ❑ Explosives❑ Detonating cord ❑ with projectiles every ft ❑ without projectile ❑ Other Elro Detonating cord and boosters ❑ with projectiles P , every ft ❑ without projectile Seaaterial Neat Cement(94 lb bag/5-6 gal water) Sand Cement sack mix/7 gal water Bentonite Pellets Seal (20%solids) Manufacturer Spec%solids_% Name Specs on File Specs Submitted Placement Method ped Free Fall Other Seal Completion Complete with Mushroom Cap / 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 HE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION WS. ADVANCE NOTICE REQUIRED FOR INSPEC iON" A qq CONTRACTORS SIGNATURE TITL DATE `� V -F i ...._M_...._._..I. ' f......T.._...1. F 1...._-t i V I -...1-......�.....-... 4 7_...y` {. r .. J r .... Wiliiilq t.. jj n F..... 1..,_...;....._......._. I _ ............... i , I ;....._.._....�_.-.3 i _.... ,.................L....... ....- a r.._.. k_... I i_. , LDEPARTMENT USE QN Y ^� f'- Application Accepted By I� - Date ' r� G�� Area Destruction Inspection By 4 - -7 /�-�. Employee ID# / COMMENTS .' I T 1 n G� { S w PE SC Received Check#/ Amount Permit/ Codes Info &ZCash Remitted Date Service Re Lest# Invoice# Well ID# OLA V` n EHD 43-08