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WELL DESTRUCTION PERMIT PUBLIC WATER SYSTEM ❑Yes� SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE 3"n FL-STOCKTON CA 95202 - (2099)468-3420 NON-REFUNDABLE PERMIT CALL(209)953-7697 FOR INSPECTIONS �jEXPIRES I YEAR FROM DATE ISSUED JOB ADDRESS Z 7 7'o ///C�1�� CITY/ZIP Y/V✓/l� / G �y r� to iT �V APN / /��'�y CROSS STREET C�/. - {{t6 ip�/,,'_P�ARCEL SIZE LAND USE APPLICATION# o OWNER 90 ryJ,VA'�/�/�1�_� /n��/t 4g'1'k`t� P0� OWNER ADDRESS / ''c/s7//L CITY/STATE/ZIPP y CONTRACTOR /JI� �� i %�� C+--THONE CONTRACTOR ADDRESS �� / J� CITY/STATE/ZIP / ❑ C-57 WELL DRILLING LICENSE NUMBER �ir/'fey EXPIRATION DATE S -' 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 ❑ Dry ❑ Replacement Well V Caved In 0 ❑ Pit Well Inactive ❑ Test Hole Detected/Suspected Well Water Contaminant(s) Adjacent property with contamination (Address) Known Soil/Water contaminants at adjacent property S EXISTING WELL CONSTRUCTION DETAILS ❑ Open Bottom ❑ Gravel Pack ❑ Uncased ❑ Other Well Log copy attached ❑ Yes ❑ No Grout Seal ❑ No ❑ Yes ft below ground surface(bgs) Hole Diameter inches Well Conductor Casing ❑ Yes ❑ No Depth of Conductor Casing ft bgs Diameter of Conductor Casing inches Well Casing Diameter inches Total Depth tl Depth to Water ft Depth of Casing ft bgs DESTRUCTION SPECIFICATION Sealing Material from ft bgs to ft bgs Filler Material from ft 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 ft ❑ without projectile ❑ Detonating cord and boosters ❑ with projectiles every ft ❑ without projectile ❑ Other Sealing Material ❑ Neat Cement(94/b bag/5-6 gal water) [3 SandCement sack mix/7 gal water Bentonite Pellets ❑ Bentonite(20%solids) ❑ Manufacturer Spec%solids % Name ❑ Specs on File ❑ Specs Submitted Placement Method ❑ Pumped ❑ Free Fall ❑ Other Seal Completion P Complete with Mushroom Cap 3 ft bgs ❑ Complete to Existing Surface Pad a 1 HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN ��Wttll JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. 1 ALSO CERTIFY THAT MY REQUIRED LICENSE IS CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT 1 AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION LAWS. M 4 DVANCEE NOTICE REQUIRED FOR INSPECTIONS CONTRACTORS CONTRACTORS S GNATURE /`/!`'�^ TITLE DATE �Z PAS RFCe VNT® E AMR � � ZOZO vlf? I/COON EACTyDEpgR��NTY DEPARTMENT USE ONLY 7- Application Accepted By C Date 1 1 Area p� Destruction Inspection By Dat �2C7 Employee ID# COMMENTS r O S tj PE SC Received X Chec Amount Permit/ Codes Info B ash Remiitted Date Service-Request# Invoice# Well ID# i )1915viWOV CrT— U✓!a ,v fivp-S EHD 43-02-0% � Xh- 1/27/2005 � ✓ �I.Q0/f� /M(i•Il/'"SI�'.l,r/roe� 1V,�.m'DiW,Ocll D /u G P cCocr)c 1