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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 �� I ��< f �k� CITY/ZIP Y CROSS STREET �"V �D APN L' �J '1 GSC j© PARCEL SIZE LAND USE APPLICATION If G OWNER Y`�! l (LLrPHONE 7/, (� t� { i. OWNER ADDRESS `7 7 I J� Cr(C�; 1� CITY/STATE/ZIP ✓ �{S �� r.�j til f CONTRACTOR _ C11� � PHONES 2.,' CONTRACTOR ADDRESSCITY/STATE/ZIP I/Yn7C�za S44 6/J _ 1 C-57 WELL DRILLING LICENSE NUMBER �,G c ? EXPIRATION DATE-.Z 62 QA t PERFORATION CONTRACTOR PHONE j PERFORATION CONTRACTOR ADDRESS CITY/STATE/ZIP iyp C-57 Well Drilling License Number ExPIAO Palle �rf� ❑ Bureau of Alcohol,Tobacco and Firearms-Users of High Explosives License Number y6A n Date ❑ CHP Hazardous Material Transportation for Explosives License Number ❑ San Joaquin County Sheriff-Coroner Explosives Application and Permit License Number 6 ft�s�1�Tr �!Y ❑ California Occupational Safety Health-Blaster License Number Expiration Da)A'�A=AIT REASON FOR DESTRUCTION ❑ Dry 1�1 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 O� Open Bottom ❑ caravel Pack ❑ Uncased ❑ Other _ Well Log copy attached ❑ Yes X No Grout Seal ❑ No ❑ Yes _ It below ground surface(bgs) Hole Diameterinches 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_ /Z"J' It Depth of Casing ___ ft bgs DESTRUCTION SPECIFICATION Sealing Material from I It bgs to _ It bgs Filler Material G"�fLu�f! from �{_��ft bgs to-1_,[`C ft bgs Well casing to be perforated by one of the following methods: from _ft bgs to_ _ It 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/b bag/5-6 gal water) Sand Cement sack mix/1 gal water Bentonite Pellets i'(. Bentonite(20%solids) Manufacturer Spec%solids_ _% Name _ Specs on File Specs Submitted Placement Method Pumped Free Fa rl Other Seal Completion N 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. % MIN X HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS , CONTRACTORS SIGNATURE TITLE DATE 3 I > i i : . � T i j I � l i I __ ..__ ... .o._. i—r— .... .......,....... ....._. .__. Y._ -___.._. _ .._....— ._.. .A ... .. __ ... i i [J..» a ...... ._ , ..._. i 3 4 -T— S_/DPARTMENT USE O ,(LY Q� Application Accepted By Date Z� Zo Area 1 Destruction Inspection By ' '� 14 11 ___ Date J 1 ZIi Z01x-) Employee ID# UU/1 41 tui Vvy COMMENTS_7T Wit PE SC Received Check#/ Amount ate Permit/ Invoice# Well ID# Codes Info By Remitted Service Request# EHD 43-08 WELL DESTRUC TION PERMI i 4/30/12