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WELL DESTRUCTION PERMIT <br /> PUBLIC WATER SYSTEM ❑Y--&* <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1668 East Hazelton Avenue-STOCKTON CA 95205-(209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> -y�l N <br /> ��JJ , M� � <br /> rn <br /> JOaADDRESS Q <br /> fr G,G � i/ <br /> -' C� <br /> (�r ptJ CITY21P _=VIA <br /> CROSS STREET l/LV r L7 e��'!�rJ?APN' Oft"7' �TX/;• IJ PARCEL SIZEf0_L'kANO USE APPLICATION K <br /> OWNERJr�7li�ja 'r'i/L:���_L/�f.�<C PHONE <br /> OWER ADDREss ?L77 1"/ ArI Jr CLITY TATE/ZIPO <br /> Cr RACTOR�,/'Y'/�/!�✓t.�S �} �1�;��!'�. f'�.:�.71•/t �t�lio` 1%' ..?/l_? <br /> �CITT(STATE/ZIP <br /> !� C-57 WELL DRILLING LICENSE NUMBER �� d J ll EXPIRATION DATE <br /> PERFORATION CONTRACTOR PHONE r <br /> PERFORATION CONTRACTOR AODRasS CITY/STATE/ZIP <br /> O C-57 Well Drilling License Number Expiration Date <br /> ❑ Bureau of Alcohol,Tobacco and Firearms-Users of High Explosives License Number Expiration Date <br /> ❑ CHP Hazardous Material Transportation for Explosives License Number Expiration Date <br /> ❑ San Joaquin County Sheriff-Coroner Explosives Application and Permit License Number Expiration Date <br /> ❑ Catfomia Occupational Safety Health•Blaster License Number Expiration Date <br /> REASON FOR DESTRUCTION ❑ Dry Replacement Well ❑ Caved In ❑ Pit Well ❑ Inactive ❑ Test Hole <br /> elected/Suspected Well Water Contsmitiant(s) <br /> Adjacent property with contartlination(Address) <br /> Known Soil/Water contaminants at adjacent property <br /> EXISTING WELL CONSTRUCTION DETAILS ❑ Open Bottom ❑ G,&eI Pack ❑ Uncased ❑ Other <br /> Well Log copy attached ❑ Yes ❑ No Grout Seal D No ❑ Yes,It below ground surface(bgs) Hot*Diameter inches <br /> Well Conductor Caving❑ Yes ❑ No Depth of Conductor Casing II bgs Olamater of Conductor Casing inches <br /> `gall Casing Diameter -44—inches Total Depth-A-Z-it Depth to Watsr__7_-it Depth of Casing it bgs <br /> iDESTRUCTION SPECIFICATION <br /> Sealing Material from ft hgs to it bgs Filler Materiel from ft1g <br /> Well casing to be perforated by one of the following methods: frau If bgs to <br /> ❑ Mills Knife Number of cuts every it and/or M O <br /> •'T Explosives❑ Detonating cord ❑ wrth projectiles every tt ❑ without pr the <br /> ❑ Detonating cord and boasters ❑ with projectiles every h ❑ without pr�""VIJBV <br /> ❑ Other � C[y,,,_ <br /> Seating Material Neat Cement(94 lb bays-6 gal wafer)I Sand Cement sack mix/7 gel water allele <br /> J� Bentonite(20%solids) .J Manufacturer Spec%solids—% Name C Specs on File C Specs u ed <br /> Placement Method ,DV Pumped _, Free Fall I Other <br /> Seel Completion Complete with Mushroom Cap _It bgs Complete to Existing Surface Pad fin, 7/> <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL Be DONE IN ACCORDANCE WITH SAN <br /> JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT 1 AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br /> CONTRACTORS SIGNATURE 7/1/14I J /- TITLE �" DATE '7 T <br /> 1 <br /> 94� <br /> c <br /> I _ - <br /> 1 r'�r� DEPARTMENT USE ONLY <br /> Application Accspted By G _ - / !I _ Date A0121,40 Area TgT <br /> Destruction Inspection By Date EmployselDs <br /> COMMENTS <br /> PE Sc Received / Checks Amount Ps""W Invoices Well IOM <br /> Codes Info B -Csw Remitted Date Service Request s <br /> EHD43-08 <br /> 12 <br /> 4/3(Y12 WELL DESTRUCTION PERMIT <br />