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WELL DESTRUCTION PERMIT <br /> PUBLIC WATER SYSTEM ❑Yes-&* <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 East Hazelton Avenue-STOCKTON CA 95205-(209)468.3420 <br /> NON-REFUNDABLE <br /> PERMIT <br /> ,l CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> Joe ADDRESSCm/ZIP <br /> CnOSS STREET /V r ///�. JTAPN' OQ"7" �TX/.-_. �� PARCEL SIZE!/6LAND USE APP/Lic:ATKNI a O <br /> OWNER ET�/` // �lT J r a,x Lr':yrz e_�/�f."�T'— PHONE /!/O <br /> OwveR ADDRESS Z33fr I C//IT,,,Y TATE/ZIP 1 e <br /> C r.RACTOR / -I �� r i r/leilo `� <br /> C, -iiAC?omADDRE35 -7I?r� CITT(STATERIP ezr?_ <br /> I, C-57 WELL DRILLING LICENSE NUMBER /yXd d ll EXPIRATION DATE <br /> PERFORATION CONTRACTOR PHONE <br /> PERFORATION CONTRACTOR Aconites 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 /> ❑ California Occupational Safety Health-Blaster License Number Expiration Date <br /> REASON FOR DESTRUCTION ❑ Dry 0 Replacement Well ❑ Caved In [3 Pit Well ❑ Inactive ❑ Test Hole <br /> Detected/Suspected Well Water Contemiffant(s) / �1/fir❑ 1=` <br /> Adjacent property with contamination(Address) <br /> Known Soll/Water contaminants at adjacent property <br /> EXISTING WELL CONSTRUCTION DETAIL G ❑ Open Bottom ❑ G,evel Pack ❑ UnCased ❑ Other <br /> Well Log copy attached ❑ Yes ❑ No Grout Seel ❑ No ❑ Yes_It below ground surface(bgs) Hole Diameter inches <br /> Well Conductor Casing❑ Yes ❑ No Depth of Conductor Casing It bgs Dlstnater of Conductor Casing inches <br /> Well Casing Diameter--&—inches Total Depth—16Z II Depth to water_-it Depth of Casing it bgs <br /> iDESTRUCTION SPECIFICATION <br /> Sealing Material from ft bgs to it bgs Filler Materiel from it bg0k Xgs <br /> Well casing to be perforated by one of the following methods: from h bgs to -_ae O <br /> ❑ Mille Knife Number of cuts every it and/or MAp n <br /> •., Explosives O Detonating cord ❑ with projectiles every it ❑ without pr ' MAW V <br /> ❑ Detonating cord and boosters ❑ with projectiles every ft ❑ without pro�sf�UW <br /> ❑ Other M L��o <br /> Sealing Materiel Nest Cement(94 Ib bag/5-6 gaf water)1 Send Cement sack mW7 gal water allele <br /> Bentonite(20%solids) .i Manufacturer Spec%solids % Name L Spec on File FSpecs u ad <br /> Placement Method Pumped i Free Fall Other <br /> Seal Completlon Complete with Mushroom Cap it bgs V Complete to Existing Surface Ped A4-K' 7NC1' <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> JOAOUIN 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 I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> /NI IA)I}IJ ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br /> CONTRACTORS SIGNATURE V"7171 J j- TITLE e DATE <br /> ....—j....:_. SIG .- ---_ <br /> —.. . <br /> —1 _1 <br /> .l. <br /> ttk <br /> DEPARTMENT USE ONLY <br /> / i <br /> Application Accepted By—r`TZ G L.-- _ Data _001120AO Area <br /> Destruction Inspection By Data Emp"IDs <br /> COMMENTS <br /> PE SC Received Checka9 Amount Date Permit/ Invoice a WeII 101111Codes !!info B —CasK Remitted Service R ueot a <br /> EHD43-08 <br /> l2 <br /> 4/3U/12 WELL DESTRUCTION PERMIT <br />