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WELL DESTRUCTION PERMIT PUBLIC WATER SYSTEM ❑Yes ❑No SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1980 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 CrTY/ZJP l Cw aGZj3� 7 CROSS ST E APN PARCEL SIZE 14LAND USE APPLICATION 0 OWNER PHONE OWNER ADDRESS CITYISTATE/LP . CONTRACTOR PHONE CON�TRACTOn ADORES9 CfTYISTATEMP Lit C37 WELL DRILLING LICENSE NUMBE3M&R EXPIRATION DATE U�-o/l/- 102-� PERFORATION CONTRACTOR PHONE PERFORATION CONTRACTOR ADDRESS CfTY/STATE/ZIP ❑ C-57 Well Drilling License Number Explrallon Dale ❑ Bureau of Alcohol,Tobacco and Firearms-Users of High Explosives License Number Expiration Date ❑ CHP Hazardous Material TransporlatIon for Explosives License Number Expiration Dale ❑ San Joaquin County Sheriff-Coroner Explosives Application and Permit License Number Expiration Data ❑ California Occupational Safety Health-Blaster License Number Expiration Date REASON FOR DESTRUCTION ❑ Dry ❑ Replaceme t Well ❑ Caved In ❑ Pit Well K Inactive ❑ Test Hole Delecled/Suspected Well Wsler Contaminenl(e) Adjacent property with contamination(Address) KnowAdIlWater contaminants at adjacent property Ilk ExISRNG WELL CONSTRUCTION DETAILS —19 Open Bottom ❑ Gravel Pack ❑ Uncesed ❑ Other Well Lag copy attached ❑ Yes No Grout Seel ❑ No ❑ Yes it below ground surface(bgs) Hole Diameter inches Well Conductor Casing Yxe/s No Depth of Conductor Casing_ It bgs Diameter of Conductor Casing inches Well Casing Dlsmatar _Inches Total Depth ,JD II Depth to Water T� II Depth of Casing It bgs DESTRUCTKINSPEM ATKIN Sealing Materiel from C*) h bgs to 100 It bgs FIIhrMsI"W from It bgs to It bgs Well casing lobe perforated by one of the following methods: from It bgs to—it bgs ❑ Mills Knife Number of cuts every R and/or ❑ Explosives❑ Detonating cord ❑ wilh projectlles every it ❑ without projectile ❑ Detonating cord and boosters ❑ with projectiles every it ❑ without projectile ❑ Other Sealing Material T Neat Cement(94 lb bag15-6 gal water) Send Cement sack mlx/7 gal water )f Bentonite Pellets I Bentonite(20%solids) i-, Manufacturer Spec%solids Name Specs on File I Specs Submitted Placement Method Pumped " Free Fall - Other Seel Completion X Complete with Mushroom Cep- 3 it bgs Complete to Existing Surface Ped 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. 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. MINIMUM HOUR ADVANCE NOTICE REQUIRED FOR NSPECTIONS CONTRACTORS SIGNATURE TITLE I DATEM'?�ft /��/j - -t- _ pq Y -- --- - - -- PR ?g - - - - __ q 2020 F Q- -- —— — - — J- — - —-- — -- _ U/N OFpgR M� - —-- — - --- -- —— -- — -- — — — FNT DEPARTMENT USE 0NJLY/. ) Appilcatlon Accepted By G� Date HTS/-b,z, Area q`/ II' Destruction Inspection By Date___._ I Employee IDR v COMMENTS /�12 In}el,, 6f tp?e coiS�nG Lbcll) (ivif hC r.lecsYeC/�"D Vie 1nc�`P tT(ll/ o�S1YU4flViIS r4�lIC� >MigH>` ;nfer4'ere �I, Yh v(I �I:�I(re sr�tlinu }I;DrL�cl�ves PE SC Received Check#/ Amount Date Perm'V Invoice R Well 100 Codes into Bv r2ash Remitted_ Se toe Re uesI 0 12 EHD 4300 �� J/-- WELL DESTRUCTION PERMIT 413(VI2