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49 <br /> WELL DESTRUCTION PERMIT <br /> PUBLIC WATER SYSTEM ❑Yes ❑No <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 East Hazelton Avenue-STOCKTON CA 95205-(209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS .C-^• ,,ff((,J/ P I (� � CITY/ZIP <br /> N VAI <br /> CROSS STREET UCG U V V VI . /APN V'r ��I— C L-D <br /> PARCELSIZ;�v LtANDr,,USE APPLICATION# O <br /> OWNER M I <br /> PHONE <br /> OWNER ADDRESS x1 " L- CITY/STATE21P I �+ Vj�' �O`V�J(Jr,/_-7_,3V <br /> CONTRACTOR C IWA / 201 <br /> I PHONE ZI `(2 �•-� <br /> 'CONTRAPTOR ADDRESS f+' y t ) ( 11•nn ",r�1 CITY/STATEIZIP <br /> 12 C-57 WELL DRILLING LICENSE NUMBER \ r 1,y(L/L rl(..•L.. EXPIRATION DATE <br /> PERFORATION CONTRACTOR PHONE <br /> PERFORATION CONTRACTOR ADDRESS CITY/STATE/ZIP <br /> ❑ C-57 Well Drilling License Number Expiration Date <br /> ❑ Bureau of Alcohol,Tobacco and Firearms-Users of High Explosives License Number Expir Dyate <br /> ❑ CHP Hazardous Material Transportation for Explosives License Number Exp,I�3t�6 �A1 <br /> ❑ San Joaquin County Sheriff-Coroner Explosives Application and Permit License Number Exp ttt4 ;�f�--- <br /> ❑ California Occupational Safety Health-Blaster License Number Ex tion Date-�GJ <br /> REASON FOR DESTRUCTION Dry •"f Replacement Well ❑ Caved In Pit Well ❑ Inactive a oro <br /> Detected/Suspected Well Water Contaminant(s) SMI,/ II�� <br /> Adjacent property with contamination(Address) VIR OU <br /> Known Soil/Water contaminants at adjacent property DEP <br /> EXISTING WELL CONSTRUCTION DETAILS Open Bottom ❑ Gravel Pack ❑ Uncased ❑ Other <br /> Well Log copy attached ❑ Yes 0 No 'Grout Seal ❑ No ❑ Yes ft below ground surface(bgs) Hole Dia=' inchesWell Conductor Casing❑ Yes ❑ No Depth of Conductor Casing It bgs Diameter of Conductor Well Casing Diameter 7 inches Tota Depth (->6� it Depth to Water 0"'al-- ft Depth of C <br /> DESTRUCTION SPECIFICATION <br /> Sealing Material from SCI ft bgs to C ft bgs Filler Material from It bgs to ft bgs <br /> Well casing to be perforated by one of the following methods: from It bgs to It bgs <br /> ❑ Mills Knife Number of cuts every ft and/or <br /> ❑ Explosives❑.-,Detonating cord ❑ with projectiles every It ❑�without projectile <br /> ❑ Detonating cord and boosters ❑ with projectileslevery It Qwithout projectile <br /> ❑ Other / <br /> Sealing Material ❑ Neat Cement(94 Ib bag/5-6 gal water)❑ Sand Cement 10. sack mix/7 gal water 0(Z. kX Bentonite Pellets <br /> :BentoRite.ROZ.�I L&J❑ Manufacturer Spec%solids % Name ❑ Specs on File //❑�� Specs Submitted <br /> Placement Method yK Pumped ❑ Free F I ❑ Other <br /> Seal Completion U Complete with Mushroom Cap ft bgs ❑ Complete to Existing Surface Pad <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> MINIMUM H R ADVANCE NOTICE REQUIREDDORIPECTIONS <br /> CONTRACTORS SIGNATURE —. . :IP '/ � ITLE � / DATE <br /> 7: <br /> u <br /> I f <br /> _D,EPA TMENT USE <br /> Application Accepted By _( 711E Date`' T 1 Area <br /> Destruction Inspection By Date Employee ID# <br /> COMMENTS <br /> PE SC Received he Amount Permit/Codes Info B Cash emitted Date Service Re ue # Invoice# Well ID>t <br /> WFII nFCTRI Ir.TION PFRMIT <br />