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WELL DESTRUCTION PERMIT PUBLIC WATER SYSTEM ❑Yes allo SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPT 1868 East Hazelton Avenue-STOCKTON CA 95205.6232 -(209)468-3420 NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS J• �U(L' L-'.Eh�Nl-r �'Lam— CITv(ZIPL'Sir/fLG/� L/� <<S�'�6' 3�/ CROSS STREET 'Jt/D�Yf APN:T y -'fLL •l�C _ C PARCEL SIZE/LALAgpr NSD,USE APPLICATION# OWNER K,r��1C1 V 5/ELA'`S PHONE(�"G%Y / D•S J S i OWNER ADDRESS'XU{� J yy Jar//L t F!� �, r CITY/STATE/ZIP CONTRACTOR S- CONTRACTOR ADDRESS /'/ Sr C v� S//� C�/ CITY/S7ATEIZIP C-57 WELL DRILLING LICENSE NUMBER EXPIRATION DATE PERFORATION CONTRACTOR PHONE PERFORATION CONTRACTOR ADDRESS CITY/STATE/ZIP f� 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 ContamiAan(s) Adjacent property with contamination(Address) Known Soll/Water contaminants at adjacent property ExISTING WELL CONSTRUCTION DETAILS ❑ Open Bottom C 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 Al.nr C- ft bgs Diameter of Conductor Casing t //1� inches Well Casing Diameter inches Total Depth��ft Depth to Water Z-,9 Depth of Casing�— ft bgs DESTRUCTION SPECIFICATION Sealing Material from 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 pA ❑ Mills Knife Number of cuts every ft and/or I� ❑ Explosives Detonating cord ❑ with projectiles every ft ❑ without projectile ��/ ❑ Detonating card and boosters ❑ with projectiles every ft ❑ without projectile ❑ Other O Sealing Material Neat Cement(94 lb bagf 5-6 gal water) Sand Cement sack mix/7 gal water Bentonite Pellets 4R 23 Bentonite(20%solids) Manufacturer Spec%solids_% Name Specs on File Specs SubSd ecl 20 Placement Method Pumped Free Fall Other ��tt ?0 �--- Seal Completion Complete with Mushroom Cap -' ft bgs Complete to Existing Surface Pad / q A/ I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SA ORDINANCES,JOAQUIN COUNTY SEP FN�UN�y, CURRENT AND CTIIVEWITH THECALIFORNIA CONTRACTORSTATE LAWS, AND RULES STATELICENSEBOARD AND THAT I AM INLATiONS. I ALSO CERTIFY THAT YCO COMPLIANCE REQUIRED (WITH ALCENSE L �RTMF/yT WORKERS COMPENSATION LAWS. MINIMUM 48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS CONTRACTORS SIGNATURE x / �� - TITLE //6�N/ DATE r — _. — I I - I I t --..._.- -.. _..__...._ L�11 • P„A MENT USE 0 N L Application Accepted By / Date Area Destruction Inspection By \,� Date Employee A4 COMMENTS PE SC Received Check#/ Amount Permit/ Codes Info Cash emitted Date Service Request# Invoice# Well ID# EHD 43-08 /D/ G��l� / WELL DESTRUCTION PERMIT revised 4/14/18