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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 -_III �'... I < %.,-_)1OV IL•�i CITY/ZIP- CROSS STREET APN l�'q,./., ..,.;'c•'••?l/ ' PARCEL SIZE LAND USE APPLICATION# o OWNER__ "•/"``1 h{:� / PHONE r t CY/STATE/ZIPOWNER ADDRESS y- CONTRACTOR PHONF,>'1 -! I CONTRACTOR ADDRESS. jr, CITY/STATE/ZIP -� 'ft, C-57 WELL DRILLING LICENSE NUMBER (•"f;`?�}'!r . EXPIRATION DATE_-!' n PERFORATION CONTRACTOR PHONE P — PERFORATION CONTRACTOR ADDRESS CITY/STATE/ZIP -- ♦ `. C-57 Well Drilling License Number FF/�� I tion Date ❑ Bureau of Alcohol,Tobacco and Firearms-Users of High Explosives License Number �4 b ❑ CHP Hazardous Material Transportation for Explosives License Number SAIVF,�pj-qeq ��NDaate ❑ San Joaquin County Sheriff-Coroner Explosives Application and Permit License Number "` 0 /y ❑ California Occupational Safety Health-Blaster License Number >�' -- REASON FOR DESTRUCTION ❑ Dry :j 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 L EXISTING WELL CONSTRUCTION DETAILS Open Bottom ❑ Gravel Pack ❑ Uncased ❑ Other Well Log copy attached ❑ Yes pl 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' e,' inches Total Depth:/J(f� it Depth to Water f'.,J It Depth of Casing it bgs DESTRUCTION SPECIFICATION Sealing Material from ft bgs to ft bgs Filler Material +u e i from )z,';. ft bgs to _lit 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 rl Neat Cement(94 Ib bag/5-6 gal water)ri Sand Cement sack mix/7 gal water n Bentonite Pellets i( Bentonite(20%solids) U Manufacturer Spec%solids—% Name ❑ Specs on File `J Specs Submitted Placement Method n Pumped n Free Fa,11—, n Other Seal Completion LN. Complete with Mushroom Cap _ft bgs L 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. ,/f F['7 MINIMUM N HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS CONTRACTORS SIGNATURE TITLE - DATE I i I ' ... _ry..f... .................._............. . ._._, _..__._.........-... ._. _. .� .....__.,._..._. i I D;tPARTMENT USE ONLY ' Application Accepted By /f -- - Date r iZ' _ Area Destruction Inspection By Date Employee ID# COMMENTS PE SC Received CheckW., Amount Permitt Codes Info By Remitted Dat11 e Service Request# Invoice# Well ID# FHn da-nn l WELL DESTRUCTION PERMIT