WP0040499 - Laserfiche WebLink

Home Browse Search

WELL DESTRUCTION PERMIT 4 PUBLIC WATER SYSTEM ❑Yes ❑No SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPT 1868 East Hazelton Avenue-STOCKTON CA 95205.6232 -(209)468-3420 i NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPEC70Ns PIRES 1 YEAR FROM DATE ISSUED JOB ADDRESSC _/Tigy , �A 9333 ? �4141 r Q ? ITY/ZIP CROSS STREET G If (1 APN 12 G QJ " OZ•J PARCEL SIZES LAND USE APPLICATION# 7Op OWNER A„ PHONE © N OWNER ADDRESS F� CITY/STATE/ZIP 14 967,16 CONTRACTORC n PHONE � IY6. CONTRACTOR ADDRESS O J CITY/STATE21P C ��'�-a 57 WELL DRILLING LICENSE NUMBER �7 L /� ExPIRATION DATE It PERFORATION CONTRACTOR P! PHONE 6 -'1 ' ^ /O PERFORATION CONTRACTOR ADDRESS �� CITY/STATE/ZIP16— �Q.Q C-57 Well Dnll:ng License Number 'r Q_!LI?Expiration Date f-'-J/-,2/ Bureau of Alcohol,Tobacco and Firearms-Users of High Explosives License NumberyZ Q'I! �Z7 x Iration Date. I 7oL1 CHP Hazardous Material Transportation for Explosives License Number.1'j`� 7 Expiration Date ZIPSan Joaquin County Sheriff-Coroner Explosives Application and Permit License Number JJ g rJ Expiration Date California Occupational Safety Health-Blaster License Number i,W^q/b _ Expiration Date_ l"Z-34117- REASON FOR DESTRUCTION ❑ Dry ❑ 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 prope ty I _EXISTING WELL CONSTRUCTION DETAILS ❑ Open eottom VI Pack ❑ 'Jncased ❑ Other Well Log copy attached ❑ Yes fr"No Grout Seal ❑ No ❑ Yes ft below ground surface(bgs) Hole Diameterinches EliWell Conductor Casing Yac ❑ No Depth of Conductor Casing ft bgs Diameter of Conductor Casing inches Well Casing Diameter _inches Total Depth _ J ft Depth to Water J0 ft Depth of Casing ft bgs I DESTRUCTION SPECIFY4TION Sealing Material from 6 6> ft bgs to_�ft bgs Filler Material C-&,&G AG f< from t_ft bgs to Coft bgs Well casing to be perforated by one of the following methods from t_t5 ft bgs to / 0 ft bgs I ❑ Mills Knife Number of cuts every ft and/or 1 7d r ,91.-Explosives❑ Detonating cord ❑ with projectiles every__[�__ft ❑ without projectile Q/AY' Detonating ord,Ad boosters C. with�pprojectiles every_fj ❑ without projectile / W ❑ Other �i<fF7r (�/IA1et>'f b-arFYY�3iyc .�'E"('�+hQq� t�0 �'Ri1 f 4 gCS- . Sealing Material Neat Cement(94 to bag 5-6 gal wat r) Sand Cement-s,*k mix/7 gal water Bentonite Pellets Bentonite(2� �solids) Manufacturer Spec%solids_% Name Specs on File Specs Submitted Placement Method Pumped Free Fall_ Other Seal Completion Complete with Mushroom Cap S ft 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 ACTIVE WITH&E CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION S. % A VANCE NOTICE REQUIRED FOR INSPE ,I9NS CONTRACTORS SIGNATURE TITL Of!/rA�t/ DATE 20 _...:.....1------._... ......... t C.....1.._.. _ -41--- r-7 : f -T r% j .� ......_. ._ ) +._1 fI ......:....... ... 1 , ...�.._..;-.._ .._.. ,QREss `1 ��2 Q SqN UNI'TAL p 4 JOq Q U! EALT !._ I Y �_...;._ _.... r N D ... .....:.........: i r.. -I f EPgR r. .. t } t t . L.... ;_ j._ MENT .�.i_ ( j. _ .._..._. A T M E N T USE ONLY Application Accepted By Date vv Area Destruction Inspection By Date--,7 Employee ID# COMMENTS w E;�/ n PE SC ceived ` C eck#/ Amount Permit/ Codes Info B Cash Remitted Date Service Re uest# Invoice# Well ID# EHD 43-08