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WELL DESTRUCTION PERMIT r PUBLIC WATER SYSTEM ❑Yes)(No SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPT 1868 East Hazelton Avenue-STOCKTON CA 95205-6232)(No (209)468-3420 NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS Z CITYIZIP M Q n-Y CCa 'Is?)'j'] CROSS STREETN APN '"1�'3 I Qj PARCEL SIZE4�-I AND USE APPLICATION p OWNER 0.0 O HONE ? OWNER ADDRESS CITY/STATE/ Q QOA 91 CONTRACTOR A 1 , PHONE �y'4 as� 165 CONTRACTOR ADDRESS •� O �} CITY/STATE2IP Milo'Q Q`C,5-1-0C A 9 6354 C-57 WELL DRILLING LICENSE NUMBER i+�9O `� EXPIRATION DATE 5—3 PERFORATION CONTRACTOR PHONE PERFORATION CONTRACTOR ADDRESS CITY/STATE/ZIP 2 C-57 Well Drilling License Number Z.o 0 J 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 ❑ Caved In ❑ Pit Well Inactive ❑ 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 ❑ Gravel Pack ❑ UncaSed ❑ Other Well Log copy attached ❑ Yes "I!<No Grout Seal ❑ No ❑ Yes It 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 V _It Depth to Water ft Depth of Casing ft bgs DES1'R L(11 1!V SPECIFH'ATTON Sealing Material from 0 ft bgs to J SQ_ft bgs Filler Material from- - ftbgs to _ _ft bga 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 It ❑ Without projectile ❑ Detonating cord and boosters ❑ with projectiles every It ❑ without projectile ❑ Other. Sealing Material Neat Cement(94 Ib bag/5-6 gal water) Sand Ca ent ck mix 7 gal water Bentonite Pellets Bentonite(20%solids)=.mpedu acturer Spec%solids % Name aw t y Specs on File Specs Submitted Placement Method Free Other G7 tOIYV Seal Completion Completshroom Cap_ It 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 THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION LAWS. MINIMUM 24 HOUR ADVANCE NOTICE REII' RR IN PECTIONS p� CONTRACTORS SIGNATUREWIMM • J TITLE DATE / I P1 cyn enj �RONMF 1JNry H p N qL - - EPgR7' ENr l I RT ENT USE ONL t Application Accepted By Date Area Destruction Ins ection By Data 1 �-.)Employee I COMMENTS / t- L. � PE Sc Received Chec Amount Date Permit/ Invoice fl Well ID# Code Info B as emitted �p Service Re uest# 2.O ' EHD 43-08 WELL DESTRUCTION PERMIT 10/5107