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WELL DESTRUCTION PERMIT <br /> PUBLIC WATER SYSTEM ❑Yes ❑No <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 EXppPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS CrTY/ZIP I/ <br /> 1 I L6U, g9z�3L <br /> CROSS STE YYY _ <br /> ^ <br /> APN PARCEL SIZE LAND USE APrPLICATION M � � <br /> OWNERt�micyfuk . PHONE v <br /> OWNERADDR r CITY/STATEIZIP <br /> J <br /> CONTRACTOR PHONE 2 <br /> CONTRACTOR � <br /> > <br /> J <br /> ( —CITY/STATE/ZIP <br /> W C-57 WELL DRILLING LICENSE NUMBER U1 EXPIRATION DATE <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 ❑ Replace me t Well ❑ Caved In ❑ Pit Well A Inactive ❑ Test Hole <br /> Detected/Suspected Well Water Contaminant(a) <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 Seel ❑ No ❑ Yes ft below ground surface(bgs) Hole Diameter inches <br /> Well Conductor Casing❑ Yep lQ No Depth of Conductor Casing___- _ .._ft bgs Diameter of Conductor Casing ___.inches <br /> i <br /> Wall Casing Diameter. inches Total Depth 1�_It Depth to Water, 7IO It Depth of Casing _ it bgs <br /> DESTRUCTION SPECIFlCATION <br /> Sealing Material horn O If bgs to_/00 it bgs FIIYsMAa11aW from ft bgs to ft bgs <br /> Well casing to be perforated by one of the following methods:_- from k bgs to _If bgs <br /> ❑ Mills Knife Number of cuts every ft and/or <br /> ❑ Explosives❑ Detonating cord ❑ with projectiles every it ❑ without projectile <br /> ❑ Detonating cord and boosters ❑ with projectiles every ft ❑ without projectile <br /> ❑ Other <br /> Sealing Material Neat Cement(94 1b bag5-6 gal water) Sand Cement sack mix17 gal water Bentonite Pellets <br /> Bentonite(20%solids) Manufacturer Spec%solids Name._. Specs on File Specs Submitted <br /> Placement Method Pumped Free Fall Other <br /> Seal Completion)( Complete with Mushroom Cap . 3 tt bgs Complete to Existing Surface Pad <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 /> MINIMUM WHOUR ADVANCE NOTICE REQUIREDFLL�LO�R)INNSPECTIONS <br /> CONTRACTORS SIGNATURE TITLE 1/'((('���I�1f("1 DATE /= <br /> FCF�W NT <br /> --- - -- - _ � QUIN <br /> NT <br /> --4-U-H <br /> DEPARTMENT USE ONLY <br /> Application Accepted By G Deb 4101 ZOZ-0 Ar. <br /> Destruction Inspection By __ Date �� Employee IDN <br /> COMMENTS%He inhrIor of the tm;n4 shrill f;ysf be c.lecired 4-o eler-lneJe 61 V obstruc}wvtS ,,,li Oi <br /> m;&f inie4eieP FFetme'&eIL'lima ofcced"Yes, <br /> c r c+ <br /> Cf S ot'r S i o- C 44,1,41 torn, i Zo O <br /> L e - ,� <br /> PE SC Roesfead CheekW Amount Permit/ <br /> Date Invoice It Well IDN <br /> Codes Info B ash Remitted Service Request M <br /> x'373 16i //19s` ^- <br /> EHD 43-08 --- WELL DESTRUCTION PERMIT <br /> 4,30112 <br />