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WELL DESTRUCTION PERMIT PUBLIC WATER SYSTEM ❑Yes ❑No SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPT 1868 East Hazelton Avenue-STOCKTON CA 95205.6232 -(209)468.3420 NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS V Pin, �I r'/� CITYMP .,[� -<-�� l ✓ t CROSS STREET r L APN,/JZ 7 `7�/D O PARCEL SREUSE APPLICATION# OWNER r a 7 r.�7r W}�� PHONE P OWNER ADDRESS(45' O(1 Y1 .T�,r ` Q� CITY/STATE21P � 4i eC'�I<h - cI-�- CONTRACTOR D G :I,/ (�,�4-S PHONE CONTRACTOR ADDRESS I-//'I V.-' CITY/STATE/ZIP C-57 WELL DRILLING LICENS/7E NUMBER -1 0 EXPIRATION DATE PERFORATION CONTRACTOR I C7 ✓'G- PHONE PERFORATION CONTRACTOR ADDRESS L O Z CITY/STATE/ZIP C-57 Well Dulling License Number ExpirYn Date Bureau of Alcohol,Tobacco and Firearms-Users of High Explosives License Number FpirCHP Hazardous Material Transportation for Explosives License Number Exp ri a bat 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 ❑ Caved In ❑ Pit Well Inactive ❑ Test Hole Detected/Suspected Well Water Contaminant(s) Adjacent property with contamination(Address) Known Soil/Water contaminants at adjacent property EXISTING WELL CONSTRUCTION DETAILS ❑ Open Bottom Gravel Pack ❑ Uncased ❑ Other Well Log copy attached ❑ Yes 'Ek 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 y Inches Well Casing Diameter Inches Total Depth � 0 ft Depth to Water/:�-- ft Depth of Casing ,r0 It bgs DESTRUCTION SPECIFICATION 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 it and/or Q Explosives❑ Detonating cord ❑ with projectiles every It ❑ without projectile la Detonating cord and boosters ❑ with projectiles every It ❑ without projectile ❑ Other Sealing Material Neat Cement(94 lb bag/5-6 gal water) Sand Cement 3 sack mbrl7 gal water Bentonite Pellets Bentonite(20%solids) Manufacturer Spec%solids_°/o 1Vam on File Specs Submitted Placement Method ed Free Fall Other Seal Completion Complete with Mushroom Cap It bgs Complete to Existing Surface Pad I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I 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. MINIMUMMMMMMMMM}6 HOUR ADVANCE OTICE REQUIRED FOR INSPECTIONS / CONTRACTORS SIGNATURE Trn. ATE 3 Z� i �C �1 FIVE® I I — S,yN� R 19 ?�20 A�NMFTAL OUN7Y AO' D FEP N ARTMENT DEPARTMENT USE ON Y A lication Acce ted B Date—3 � Area PP P Y Destruction Inspection Date Z'9 7-v Employee # LL- a'YU / S t �� COMMENTS � J PE SC Received sc Amount Date Permit/ Invoice# Well ID# Codes Info B Cash Remitted Servive Request# EHD 43-08 WELL DESTRUCTION PERMIT revised 4/14118