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WELL DESTRUCTION PERMIT PUBLIC WATER SYSTEM ❑Yes ❑No 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 INSPECTIONSc EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS 7/Ln I l r�AyC�1 l i-�O S-7 �/ CrfY/ZIP_�� 'ate K]pT4 -225,015: CROSS STREET ��Rµ►N (l� APN /�� Q� Q 7(�1PARCEL SIZE_LANDD USE APPLICATION+#� OWNER- y� PHONE�C)��V�.l3O '7. ?-3 OWNER ADDRESS ,D. pQr Fa F3 CITY/STATEE/L^P E5CjLLA)t� c��/ n� CONTRACTOR / ►�/( ( PHONE �rY -�Sf�T `-('L CONTRACTOR ADDRESS ? 5?(p 1 L C EN P-1? Qlij E CIT'/STATE/LP 5 C-57 WELL DRILLING ` LICENSE NUMBER C EXPIRATION DATE Ze' i PERFORATION CONTRACTOR Y �� PHONE PERFORATION CONTRACTOR ADDRESS CrrY/STATEIZIP ❑ 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 DESTRUcnON ❑ Dry ❑ 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 EXIsnNG WELL CONSTRUCTION DETAILS ❑ Open Bottom ❑ 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 Pasing ft bgs r Diameter of Conductor Casing inches Well Casing Diameter L�1 inches Total Depth it Depth to Water It Depth of Casing It bgs DESTRUCTION SPECIFICATION i Sealing Material from (.9 ft bgs t ft Filler Material ( from U& ft bgs to bgs Well casing to be Derforated by one of the following mgthods: from ft bgs to ft bgs 4-1111111s Knife Number of cuts every _ft and/or h Explosives❑ Det rating cord ElP�with projectiles every ft ❑ without projectile /��/Isf El Detonating cord and boosters ❑ with projectiles every ft ❑ without projectile ❑ Other Sealing Material Neat Cement(94 lb bag/5-6 gal water) Sand Cement sack mix/7 gal water Bentonite Pellets Bentonite(20%solids) Manufacturer Spec%solids % Name Specs on File Specs Submitted /i Placement Method Pumped Free Fall 7 Other V 1920 Seal Completion Complete with Mushroom Cap S ft bgs Complete to Existing Surface Pad SAN J �01� I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WI AQU(N JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICE S S' CoUNTI CURRENT AND WORKERS COMPENSATIONACTIVE WITH�HE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL h EP AN r MI MUM 48 HOUR ADVANCE NOTICE REQUIRED OR INSPECTIONS CONTRACTORS SIGNATU �` TRLE S' DATE4 ' wo f EPA T M E N T USE ONL Application Accepted By 11, Data Area Destruction Inspection By Date Employee ID# + C MMEN7 �3`� f W- e& PE SC Received Check#! ' Amount Permit/ des Info Remitted Date Service Request# Invoice# Well ID# EHD 43-08 WELL DESTRUCTION PERMIT revised 4/14/18