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WELL DESTRUCTION PERMIT PUBLIC WATER SYSTEM❑Yes ❑No SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE 3101 FL-STOCKTON CA 95202 -(209)468-3420 NON-REFUNDABLE PERMIT CALL(209)953-7697 FOR INSPECTIONS EXPIRES I YEAR FROM DATE ISSUED JOB ADDRESS • GAJ I CITY2IP e 9 v CROSS STREET S :) - APN 2,26—/��1 7 PARCEL SIZE �Q �7A�USE/ CATION# p OWNER .1•'C►'� PHONE n �- OWNERADDRESS Z S CITYISTATEIZIP CONTRACTOR �/LI � 114 PHONE X22 CONTRACTOR ADDRESS I 2r CITY/STATE/ZIP—&t—&-14Af C-57 WELL DRILLING LICENSE NUMBER G ve� EXPIRATION DATE PERFORATION CONTRACTOR PHONE PERFORATION CONTRACTOR ADDRESS CITY/STATE/ZIP ❑ C-57 Well Drilling License Number Expiration Date ❑ Bureau of Alcohol,Tobacco and Firearms-Users of High Explosives License Number Expiration Date !n ❑ CHP Hazardous Material Transportation for Explosives License Number Expiration Date ❑ 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 10�Gravel Pack ❑ Uncased ❑ Other Well Log copy attached ❑ Yes f(7 iNo 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 inches Well Casing Diameter _inches Total Depthe!j�'�fl Depth to Water_ft Depth of Casing ft bgs DESTRUCTION SPECIFICATION Sealing Material from ft bgs to R bgs Filler Materialfrom /O© it bgs to ft bgs Well casing to be perforated by one of the following methods: from It bgs to R bgs ❑ Mills Knife Number of cuts every ft and/or ❑ Explosives ❑ Detonating cord ❑ with projectiles everyft ❑ without projectile ❑ Detonating cord and boosters ❑ with projectiles everyft ❑ without projectile ❑ Other Sealing Material ❑ Neal Cement(94/b bag/S-6 ga/wafer) ❑ Sand Cement sack mix/7 gal water Pgollentonke Pellets ❑ Bentonite(20%solids) ❑ Manufacturer Spec%solids % Name ❑ Specs on File Specs Submitted Placement MetTiod-0 -NnipedOK Free Fall ❑ her Seal Completion :�Complete with Mushroom Cap ft bgs Complete to Exlatiag Surface Pad 1 HEREBY CERTIFY THAT 1 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 1 AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION LAWS. MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS CONTRACTORS SIGNATURE !�I !' /'LLCLD�•(L/ TITLE� S-i&ti" DATE —2 T—r& AUG 3 0 Zo�6 ® 47Uw^p SAN JOAQUIN COUNTY ENViRONMENTAL HEALTH DEPARTMENT �> t.)11 q 9,4 �-E S-E-O N L Y -- �-- - f 7YIAY�� ` V - Area a Application Accepted By Date (� 1yyA Destruction Inspection By Tom.i t t »�s Date ! a '.i b Employee ID# L 1 t COMMENTS—Z".4-.1d, Jok. PE SC Received Cha Amount Date Permit/ Invoice# WellID# Codes Info B Cash Remitted Service R uesl# S CJ�,Oo W011 Ofti—tion Permit EHD 43-02-008 1/2712005