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` WELL DESTRUCTION'PERMIT <br /> PUBLIC WATER SYSTEM ❑Yes ❑No <br /> SAN:JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 Eaat Hazelton Avenue-STOCKTON CA 95205-(209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL(209)15­3.+7,097 FO,R INSPECTIO145 EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS 7 Lr 9 - b f G� � CITY/ZIP. <br /> ,,CROSS.STREET_/(YL {J ?'4 _APN,Z!eR-/-5-0.+t-t w i PARCEIXSIIZE,�LAND USE APPLICATION# ro3 <br /> 'OWNER IV`0..r'a't, 1]6C.1CY`a�.�r-7 r ( r PHONE [�9 IBJ.1; �.✓� (� <br /> .OWNER ADDRESS L!"*'� y9 / la:l f///'"M `�' CITY/STATECZip r r ,� <br /> CONTRACTOR $ PHONEZ.cP. <br /> .CONTRACTOR ADDRESS I J A;%eye--s' 4' ff�� CITY/STATE,/ZIP <br /> 11 (C-57WELL DRILLING LICENSE.NUMBER �WF1"Gl,� '� - EXPIRATION DATEG�,..c� <br /> PERFORATION CONTRACTOR - - PHONE- <br /> PERFORATION CONTRACTORADDRESS <br /> HONEPERFORATIONCONTRACTOR.ADDRESS CITY/STATE/ZIP <br /> ❑ C-57 Well Drilling License Number Expiration Date <br /> ❑ Bureau of Alcohol,Tobacco and Firearms Users oj'Hlgh Explosives License.NUmber Expiration Date <br /> ❑ OHP Hazardous Material Transportation for'Exploslves License Number Expiration Date <br /> ❑ San Joaquin County Sheriff-Coroner ExplosiVes Application and Permit LIceirgo Number <br /> Expiration Date <br /> ❑ California Occupatio,ppi Safety Health-Blaster Lfcanse Number Expiration Date <br /> REASON FOR DESTRUCTION D'ry ❑ Replacement Well ❑ Caved In ❑ P!tW-.1F Inactive ❑ Test Hole <br /> Detected/Suspected W6II Water Contarnihant(s) <br /> Adjacent property with contamination dress) <br /> Known Soft/Water contaminants at adj#0ht property <br /> EXISTING WELL CONSTRUCTION DETAILS ❑ Open Bottom ❑ Gravel Pack, ❑ Uncased 0 Other <br /> Well Log copy attached ❑ Yes (_No Grout'Seal ):'No ❑ Yes' ft below ground surNce'(bgs) Hole Diameter Inches <br /> Well Conductor Casing❑ Yes <No Depth of Conductor Casing ftbgs Diameter of Conductor Casing Inches <br /> Well Casing Dlameter Inches, Total Depth__{,fj_ft Depth to Water It Depth of Casing n it bgs <br /> DESTRUCTION SPECIFICATION <br /> Sealing Material from it bgs to - ft bgs Fiiler.Material_. from <br /> It bgs to It bgs <br /> Well casing to be perforated by one of-the following methods: from ft bgs to ft bgs <br /> ❑ Milts Knife Number of cuts every it''and/or <br /> ❑ Explosives❑.Detonating cord ❑ with projedies every ft ❑ without projectile <br /> ❑ Detonating cord and boosters ❑ with projectiles every ;ft ❑ without projectile <br /> ❑ Other <br /> Sealing Material ❑ Neat Cement(94 Ib bag/5-6 gal wafer)❑ Sand Cement -sack mix17 gal'water Bentonite Pellets <br /> ❑''Bentonite(20%solids) ❑. Manufacturer Spec%solids-_% Name ❑. Specs on File D Specs Submitted <br /> Placement Method D Pumped t5QFree Fall I ❑ Other f 412 0 /i ela')' ION.f <br /> Seal CompletlonX Complete with Mushroom Cap �II C� It bgs q Complete to Existing Surface Pad <br /> I HEREBY CERTIFY THAT I HAVE PFiEPARED.THIS APPLICATION AND THAT THE'WORK WILL B 'DONE IN ACCORDANCE WITH SAN <br /> JOAQUIN,COUNTY ORDINANCES, STATE LAWS,,AND`RULES AND'-REGULATIQNS:: ;I ALSO.:CERTIFY''THAT:MY REQUIRED LICENSE IS <br /> CURRENT AND ACTIVE WITH THE.CALIFORNIA.CONTRACTORS STATE LICENSE:2DA4P AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> MINIMUM41-d"HOUR ADVANCE NOTICE-REQUIRED FOR INSPECTIONS <br /> CONTRACTORS SIGNATURE TITLE/� .t Y 1.�-�.� 2'r TITLE !Jr^/ DATE <br /> VV <br /> r — - <br /> o <br /> EP RTMENT USE ONLY <br /> Application Accepted By �' l[�!i J 11 Date Area <br /> Destruction Inspection By Date Employee ID# <br /> COMMENTS <br /> i. <br /> PE SIC Received heck#/. Amount PermlU <br /> Codes Info By Remitted Data "' Servlce'Re nest M Invoice# Well ID# <br /> 7JEE ? O <br /> WFI I DFRTRI ICTION PFRMIT <br />