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WELL DESTRUCTION PERMIT PUBLIC WATER SYSTEM ❑Yes ❑No SAty JOAOUIN 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 `f Z v l I�LI1 �� CITY/ZIP Cd L 2 4 m CROSS STREET 4C-Ll k=X 04 APNZ!&-157—Z47 PARCEL SIZE LAND USE APPLICATION# Aw r OWNER PHONE (4 02-- 02- !A 0 r OWNER ADDRESS3 �7 /� O ! 7 I(sCd" 1 CITY/STATE21P �/- CONTRACTOR Y�LQ 1 p -f. I -tPHONE � 1,x^2-l.a- CONTRACTOR ADDRESS 1 1 /y'� 9 / / 7 CITY/STATE/ZIP Y'/t��IJ�e I' ❑ C-57 ELL DRILLING LICENSE NUMBER EXPIRATION DATE 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 �J 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 DETAILS ❑ Open Bottom ❑ Gravel Pack ❑ Uncased ❑ Other Well Log copy attached ❑ Yes �ie-No Grout Seal Q No ❑ Yes ___-It below ground surface(bgs) Hole Diameter inches Well Conductor Casing ❑ Yes Ot-No Depth of Conductor Casing ft bgs Diameter of Conductor Casing inches Well Casing Diameter_ 4, ' inches Total Depth__ip it Depth to Water.—Y__ ft Depth of Casing :L It bgs DESTRUCTION SPECIFICATION Sealing Material frorn It bgs to _ 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 It ❑ without projectile ❑ Detonating cord and boosters ❑ with projectiles every It ❑ without projectile ❑ Other. Sealing Material Neat Cement(94 lb bag/5-6 gal water) Sand Cement sack mix17 gal water Bentonite Pellets Bentonite(20%solids) Manufacturer Spec%solids_ °o Name _ Specs on File L Specs Submitted/ Placement Method Pumped _Free FplI �I Other ekaYna Seal Completi It bgs V%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. MINIMUMI34 HOUR ADVANCE NOTICE REQUIRED +FOR/INSPECTIONS ,Q / CONTRACTORS SIGNATURE �,cL Y /1G2.� /j� TITLE IJ:'///C 1' DATE � O^�V' / ..._....M.......... _ -- - _ ... i _........_.._......i.._._.._....._...._....._...................................................-......._..........._ _... _. ..__ _' -- -_- -_-_ __ - - ... ... .. T m - ... .. _._ : i : E I _ I 09 SAN�OA _- _ _ ��41 f CO Nry€__. y N ... _-._ _............__...-._.... .-_.i_--.__.._:__ _.__._._. rMEN j +4+44 EJ? RTMENT USE ONLY Application Accepted By- Date l Area Destruction Inspection By Date 6 Z� Employee ID# COMMENTS PE SC Received heck#/ Amount Permit/Codes Info B emitted Date Service Request# Invoice# Well ID# J T00-1 NAA W0240 `111 EHD 43-08 WELL DESTRUCTION PERMIT 4/30/12