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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_ (� J t�S P f 1 ILC CITY/ZIP M e l-r c e-A CROSS STREET v APN ZIP' '�q 'CIA PARCELSIZEC-:YI&AND USE APPLICATION# OWNER f"'\I -Q p' PHONE 6__D y- 3�Z -Z? OWNER ADDRESS `SRS CITY/STATE/ZIPYI.1"1 r 'I CONTRACTOR 660Wilis15zz CONTRACTOR ADDRESS 1 tq 4, 1 b r4J Ll CITY/STATE/ZIP 410t1 f- O ✓I C-57 WELL DRILLING LICENSE NUMBER �ry�?!. EXPIRATION DATE U Z 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 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 DESTRUCTION ❑ 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 EXISTING WELL CONSTRUCTION DET ILS Open Bottom ❑ Gravel Pack ❑ Uncased ❑ Other Well Log copy attached ❑ Ye No Grout Seal ❑ No ❑ Yes_ ft below ground surface(bgs) Hole Diameter inches Well Conductor Casing [I Ye No Depth of Conductor Casing ft bgs Diameter of Conductor Casing inches Well Casing Diameter-6—inches Total Depth Y-6—ft Depth to Water___It Depth of Casing ft bgs DESTRUCTION SPECIFICATION Sealing Material from 6 ft bgs to ft bgs Filler Material_ from ft 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 Cement sack mix17 gal water Bentonite Pellets Bentonite(20%solids) Manufacturer Spec%solids-_- % Name Specs on File Specs Submitted P acement Method Pumped Free FaIJ� 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. lib MINIM M X HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS CONTRACTORS SIGNATURE TITLE DATE -7 'd GU,�P/ iZ�-" -71 �_ ._ .._.... .........._..... ..._....._.. _..._..... i.- _ _. ..._.... - - - -- - -- - - - ._ 1.. ...... i ............................................._.I _...... I VN 43 611 i vo, 71 ...... ...... ... _ .r ..... .__t ti 0 LM : FHO '9RN� � —... _ ._ � f i Fy,P RTMENT USE ON Y Application Accepted By Date 2/ Area -7,/, Destruction Inspection ByA�� Date) 7 Employee ID# COMMENTS PE SC Received eck# Amount Date PermiU Invoice# Well ID# Codes Info B mitted Service Request# X38 IZ ' W u S� EHD 43-08 WELL DESTRUCTION PERMIT 4/30/12