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WELL DESTRUCTION PERMIT PUBLIC WATER SYSTEM ❑Yes ❑No SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 East Hazelton Avenue-STOCKTON CA 95205 - (209)468-3420 NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS '( y'� �J �/J v (/ .J w �T Y O fr-Dl. CITY/ZIP CROSS STREET U I j/�� AP)N PARCEL SIZE AND USE APPLICATION# OWNER 1�1. irlGr f�, kr'� L/V PHONE OWNER ADDRESS CITY/STATE/ZIP CONTRACTOR PHONE 327/" 912z Z CONTRACTOR ADDRESS io•6 pf,K_ �b� G CITY/STATE/ZIP " '' X_ C-57 WELL DRILLING LICENSE NUMBER �y p 2- EXPIRATION DATE 202.0 PERFORATION CONTRACTOR PHONE 3Z7 3120 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 ❑ 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 IR 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 It Depth to Water_ ft Depth of Casing g - ft bgs DESTRUCTION SPECIFICATION I / / Sealing Material from ?j --_ft bgs to � ft bgs Filler Material _ from ft 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 ❑ Detonating cord and boosters ❑ with projectiles every ft ❑ without projectile ❑ Other__ `/ Sealing Material Neat Cement(94 Ib bag/5-6 gal water) Sand Cement sack mixll gal water X Bentonite Pellets Bentonite(20%solids) Manufacturer Spec%solids % Name _ Specs on File //�`Specs Submitted Placement Method I Pumped Free fall -I Other Seal Completion Complete with Mushroom Capft 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. M IMU�JM/ HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS CONTRACTORS SIGNATURE /C� TITLE �G sl Of e,� DATE / Z PA!�!M..... .... .... .... .. ... .. i j 1 I __ .... �� ..._.._...._......._. EN OgQU/ i Vj N tr __... _ .......... .__... . NTypFp ENT�N� ..........._.. ..-..� ARTMEMT _ _... I t ! .........._........_....... _........._._. .__....._........_... .. .. .._._ ..._ _.._._..__ .... ......... .. ... ......_.._E------..._._............_._.......... ........ ............ ......._......_............... ... .......... .... t.._._... ...__.._.._._......__._._.._._. -. ESP RTMENT USE 0NL Application Accepted By Date Area Destruction Inspection By n 4G� — :pry Date �'- z �-� �'v Employee D# COMMENTS `�i! �`i//-l r.-':� ,�rJ`/�`-• f��- /t1' C"c i.!F-'��i' !�i .S.0<!,j• „ f � - PE Sc Received Check#/ Amount Permit/ Codes Info B Cash emitted Date Servi a Request# Invoice# Well ID# EHD 43-08 :I D '� /�n /n Tl WELL DESTRUCTION PERMIT 4/30/12 l-�J/ LtJ LSV