Laserfiche WebLink
WELL DESTRUCTION PERMIT <br /> PUBLIC WATER SYSTEM ❑Yes3lo <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 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 /> JOB ADDRESS � CITY/ZIP <br /> m <br /> �� c4 <br /> CROSSSTREET /✓C ZE 94 � � PARCEL SIZE ' USE APPLICATION# <br /> b <br /> OWNER cs PHONE /19/ymaG <br /> OWNER ADDRESS_ 733t gz:�> CTY�YAI�TATE21P <br /> BfiCONTRACTOR HDV <br /> CONTRACTOR ADDRESS H�D LG(�j���J CITY/STATE/ IP <br /> C-57 WELL DRILLING LICENSE NUMBER ' %��Q �� EXPIRATION DATE Z <br /> PERFORATION CONTRACTOR PHONE <br /> PERFORATION CONTRACTOR ADDRESS CITY/STATE/ZIP <br /> ❑ 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 Rep <br /> Re lace nt We I 0 Caved In ❑ Pit Well ❑ Inactive ❑ Test Hole <br /> Detected/Suspected Well Water Contami ants) <br /> Adjacent property with contamination(Address) <br /> Known Soil/Water contaminants at adjacent property <br /> EXISTING WELL CONSTRUCTION DETAILS ❑ Open Bottom ❑ Gravel Pack ❑ Uncased ❑ Other <br /> Well Log copy attached ❑ Yes ❑ No Grout Seal ❑ No ❑ Yes ft below ground surface(bgs) Hole Diameter inches <br /> Well Conductor Casing ❑ Yes ❑ No Depth of Conductor Casing ft bgs Diameter of Conductor Casing inches <br /> Well Casing Diameter ��inches Total Depth—,&Z It Depth to Water ft Depth of Casing ft bgs <br /> DESTRUCTION SPECIFICATION � <br /> Sealing Material from ft bgs to ft bgs Filler Material from ft bgs t�Gc <br /> Well casing to be perforated by one of the following methods: _ from ft bgs too <br /> ❑ Mills Knife Number of cuts every _ft and/or MAR 3 O <br /> ❑ Explosives ❑ Detonating cord ❑ with projectiles every ft 1:1without projectile ?�?� <br /> ❑ Detonating cord and boosters ❑ with projectiles every ft ❑ without projeAM Jp <br /> ❑ Other ENVIROVM COUN1y <br /> Sealing Material Neat Cement(94 lb bag/5-6 gal water) Sand Ff Cement sack mixl7 gal water �TIE4�1Qp � ets <br /> ,(f Bentonite(20%solids) Manufacturer Spec%solids _% Name Specs on File Specs Sub�� <br /> Placement Method _ Pumped rFree Fall I Other <br /> Seal Completion Complete with Mushroom Cap ft bgs Complete to Existing Surface Pad A45ti y]9�Lfe <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 I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br /> CONTRACTORS SIGNATURE- TITLE O /6�, DATE ZO <br /> SIG ._ - .... <br /> IT 144 1/ 4 <br /> (771 <br /> I <br /> Or <br /> DEPARTMENT USE ONLY <br /> Application Accepted By / _ Date i_ .32 <br /> J oZo Area �9Cy <br /> Destruction Inspection By. ! Date ` Employee <br /> rl\D# <br /> COMMENTS <br /> PE SC Received Check#/ Amount Date Permit/ Invoice# Well ID# <br /> Codes Info B Remitted Service Request# <br /> -1373 l e i I q s 2D V�`'�� �- <br /> EHD 43-08 WELL DESTRUCTION PERMIT <br /> 4/30/12 <br />