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0 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 Z ltlow - CITY/ZIP b A m CROSS STREET o PdJAPN PARCEL SIZFb LAND USE APPLICATION# OWNERWz PHONE log . OW ° 2,I0"J m OWNER ADDRESS 1442— CITY/STATCITY/STATE/ZIPUW �f/�/ "11if20W CONTRACTOR ( PHONE701 CON7'57 R ADDRESS C CITY/STATE/ZIP ! WELL DRILLING LICENSE NUMBERu u`(/,0: EXPIRATION DATE ' i PERFORATION CONTRACTOR PHONE 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 Numberiattee ElCHP Hazardous Material Transportation for Explosives License Number , 7 ❑ San Joaquin County Sheriff-Coroner Explosives Application and Permit License Number t&Vft -- ❑ California Occupational Safety Health-Blaster License Number it tion Date REASON FOR DESTRUCTION Dry Replacement Well ❑ Caved In Pit Well CL Inactive t Hole Detected/Suspected Well Water Contaminant(s) JAN JOA RO Adjacent property with contamination(Address) fiE4�r_ NMFNT , r4 Ty Known Soil/Water contaminants at adjacent property �MENT EXISTING WELL CONSTRUCTION DETAILS Open Bottom ❑ Gravel Pack ❑ Uncased ❑ Other_ Well Log copy attached ❑ Yes X 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�0 It Depth to Water� ft Depth of Casing It bgs DESTRUCTION SPECIFICATION Sealing Material from (00 ft bgs to 0 ft bgs Filler Material from It 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 CementI fl. 3 sack mix/7 gal water d(L y Bentonite Pellets ° Manufacturer Spec%solids % Name Specs on File ✓✓✓�� Specs Submitted Placement Method Pumped Free F If Other Seal Completion Complete with Mushroom Cap ft 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. y8 NII�IIUM pQ H R ADVANCE NOTICE REQUIRED FOR INSPECTIONS CONTRACTORS SIGNATURE r ITLE II"V 1 v DATE 3 �r�y1•{+r I 1 _ 1 - ..__.............._.i......-...._....... -. .._..................-._......_..._..__..._.........._...._.�....... * ... .. ... .. _....... .. ... __ ... .. ... ._ _ .. .y....._.........................................._............ ( 1 t i Ali _.... 1_........._.... ... .. i - ... --... _._....,...._._.._... ... .. . Z"lip . .. .. .-. - .. f - - -�- I i � j f _ ». ._.1__.._._......... ._.._.._ - - - i-.._. ... ....... i E E f T 1 I . ._._ ____..,, ...... _. pp PAJRTMENT USE O [ILY Application Accepted By V- Date T Area Destruction Inspection By Date 2 Z!7 Employee D# COMMENTS N (: b WI j P - l A05T I'd- nt Af�) PE SC Received CZeAmount Permit/ ode Info B / /Cash emitted Date Service Re ue t# Invoice# Well ID# 3Go(p1191 P003q59';J EHD 43-08 WELL DESTRUCTION PERMIT 4/30/12