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WELL DESTRUCTION PERMIT PUBLIC WATER SYSTEM ❑Yes ❑No SAN JOAOUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 East Hazelton Avenue-STOCKTON CA 95205 - (209)468-3420 NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS r./ 6-gewlf f. CROSS STREET ��u`L �-(/-� APN '-/0f00m% PARCEL SIZELAND USE APPLICATION# OWNER A)A OST PHONE z OWNER D S �� CITY/STATE/ZIV uZ f: CONTRACTORL-001 PHONE CONTRACTOR ADDRESS .�� r CITY/STATE/ZIP Q� C-57 WELL DRILLING LICENSE NUMBER EXPIRATION DATE PERFORATION CONTRACTOR PHONE PERFORATION CONTRACTOR ADDRESS CITY/STATE/ZIP C-57 Well Drilling License Number O g Expiration Date /Z Z� ❑ 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 Expirati ate ❑ California Occupational Safety Health-Blaster License Number Expiratir> REASON FOR DESTRUCTION ❑ Dry ❑ Replacement Well ❑ Caved In ❑ Pit Well �(Inactive Detected/Suspected Well Water Contaminant(s) / Adjacent property with contamination(Address)_ Known Soil/Water contaminants at adjacent property _ SAN-JOAQU/A Phil EXISTING WELL CONSTRUCTION DETAILS ❑ Open Bottom Gravel Pack ❑ Uncased ❑ Other Well Log copy attached ❑ Yes 40 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 /if inches Well Casing Diameter_ inches Total Depth S It Depth to Water_ ft Depth of Casing 5ft bgs DESTRUCTION SPECIFICATION Sealing Material from ft bgs to ft bgs Filler Material _from It 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 ❑ Explosives 11 Detonating cord ❑ with projectiles every _— ft ❑ without projectile ❑ Detonating cord and boosters ❑ with projectiles every _ ft ❑ without projectile ❑ Other -_ Sealing Material Neat Cement(94 Ib bag/5-6 gal water) q, nt 3 sack mixl7 gal water Bentonite Pellets Bentonite(20°%solids) Manufacturer Spec%solids____% Name """"� f'�"r? b��o�4( on File Specs Submitted Placement Method urh 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. If MIN,WM HOUR A VANCE NOTICE REQUIRED FOR INSPECTIONS CONTRACTORS SIGNATURE f4M �' �� TITLE -+�Y�� fY/ DATE 4-5, r f ` .. -I-- f— - --.. _._...___... - _ _ _.__.. _ ........_ ..._i- . ......................................................._....._......_..... ....................._..._.........._...._..............._............. .._._. __.... .. ................_....................-._.................................- ...._........................_... .__... i Poe ,0i It i E f ' I o DEPARTMENT USE L,If Application Accepted By L Date 3S Z�Zo Area S Destruction Inspection By Date 2 ZdZi� Employee ID# a Yl COMMENTS C Q r A [0. rb P-�A PE SC Received h Amount Date Permit/ Invoice# Well ID# Codes InfoRU Cash Remitted Service Request# L137_3 Z EHD 43-08 WELL DESTRUCTION PERMIT 4/30/12