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WELL DESTRUCTION PERMIT PUBLIC WATER SYSTEM ❑Yes ❑No SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPT 1868 East Hazetton Avenue-STOCKTON CA 95205-6232-(209)468-3420 NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES I YEAR FROM DATE ISSUED v, JOB ADDRESS lif/1' n CITY/ZIP /y/G o�t�- 3� CROSS STREET APN l.. 0 PARCEL SIZE YJ1ND USE APPLICATION# OWNER C"'tp rJ � F'JC� PHONE `, II p /1 OWNER ADDRESS'I.S tVJ ( mk ,JJ CITY/STATEIZIP/V � PV y IQ E'l i; GA 06 ti CONTRACTOR PHONE V CONTRACTOR ADDRESS CITY/STATE/ZIP C-57 WELL DRILLING LIC SE NUMBERz1 7 b EXPIRATION DATE PERFORATION CONTRACTOR ✓ ` r h-N PHONE PERFORATION CONTRACTOR ADDRESS CITY/STATE/ZIP ❑ C-57 Well Drilling License Number cpiration Date Bureau of Alcohol,Tobacco and Firearms-Users of High Explosives License Number t ' Dale CHP Hazardous Material Transportation for Explosives License Number on Date San Joaquin County Sheriff-Coroner Explosives Application and Permit License Number L J-al Expiration Date ) California Occupational Safety Health-Blaster License Number Expiration Dale REASON FOR DESTRUCTION ❑ Dry ❑ Replacement Well ❑ Caved In ❑ Pit Well Inactive ❑ Test Hole Detected/Suspected Well Water Contaminants) Adjacent property with contamination(Address) Known Soil/Water contaminants at adjacent property ExISTING WELL CONSTRUCTION DETAILS ❑ Open Bottom oillilk,ravel Pack ❑ Uncased ❑ Other Well Log copy attached ❑ Yes ❑ No Grout Seal ❑ No ❑ Yes It 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 4210f2ft Depth to Water J�/ft Depth of Casing-42o!10 ft bgs DESTRUCTION SPECIFICATION T Sealing Material from ft bgs to It 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 ' k Explosives❑ Detonating cord ❑ with projectiles every It ❑ without projectile ❑ Detonating cord and boosters ❑ with projectiles eve ut projectile ❑ Other Sealing Material Neat Cement(94 lb bag/5-6 gal water) Sand Cement sack mix/7 gal wate Bentonite Pellets Bentonite(20%solids nufacturer Spec%solids_ o ecs on File Specs Submitted Placement Method Free Fall Other Seal Completion Complete with Mushroom Cap ft bgs Complete to Existing Surface Pad I HEREBY CERTIFY THAT I HAVE PREPARED THIS A PLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN 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 I AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION LAWS. MINI �R AD �NCE NOTIC REQUIRED FOR iSG�IPE,CTI.ONS (/��' � CONTRACTORS SIGNATURE M� T LE ATE I , i I F - 19 M.W R AYMENT 20 - �CF,VFD MAR 9 20 20 _ JOAQUIN NVIR CDU DE RT T USE ONLY )/y /� J ! LT/1DS.,� TA�� Application Accepted By Date I`7 ! Area VI M!: Destruction Inspection B Date Employee ID# COMMENTS 'eO� U�Z lO-- S/(,rvr-_(/ t ;� /J PE SC Received Amount Date Perl Invoice# Well ID# Codes Info B Cash Remitted Service Request# 13,-Pt EHD 43-08 WELL DESTRUCTION PERMIT revised 4/14/18