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WELL DESTRUCTION PERMIT PUBLIC WATER SYSTEM ❑Yes [;?lo SAN JOAOUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 East Hazelton Avenue-STOCKTON CA 95205 - (209)468-3420 NON-REFUNDABP R IT CALL(209)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED _ r JOB ADDRESCITY/ZIP T` -S 7 CROSS STREET wZ 7 kD APN % S>'GS CG PARCEL SIZE (�AND USE APPLICATION# r � z OWNER PHONE ,Q.2 S �r�t� 1,fSLI a• _ �n OWNER ADDRESS �. / Z / f7G��'r/Cl/L 9;-'A4'I ^9 n CITY/STATE21P �,.4 i CONTRACTOR `L(Ef'-(Cyl+<( �r�ttS'�fPJcTicn� Y -��J� L1t PHONE �PL7 �v CONTRACTOR ADDRESS `/$ S •14;- 1 J<J CITY/STATE/ZIP1�,,r Lti✓1� Y� ,� ��/y�� C-57 WELL DRILLING LICENSE NUMBER i L y I y EXPIRATION DATE C+ PERFORATION CONTRACTOR "v 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 ❑ 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 ❑ Gravel Pack ❑ Uncased R Other iZ Well Log copy attached ❑ Yes C3ONo Grout Seal ❑ No ❑ Yes _- ft below ground surface(bgs) Hole Diameter 10 inches Well Conductor Casing ❑ Yes "�No Depth of Conductor Casing _it bgs Diameter of Conductor Casing inches Well Casing Diameter _ --Snches Total Depth _ vim It Depth to Water-_-_0 _ft Depth of Casing_ ft bgs DESTRUCTION SPECIFICATION Sealing Material from [eft bgs to 3C0 ft bgs Filler Material from -_ ft bgs to-- _ - ft bgs Well casing to be perforated by one of the following methods: _ -----from ft bgs to _ It bgs ❑ Mills Knife Number of cuts every ft and/or____-_- _ ❑ Explosives ❑ Detonating cord ❑ with projectiles every ft ❑ without projectile ❑ Detonating cord and boosters ❑ with projectiles every ft ❑ without projectile ❑ Other Sealing Material Neat Cement(94 lb bag/5-6 gal water)', Sand Cement __ y . 7 _ -sack mix/7 gal water Bentonite Pellets Bentonite(20%solids) Manufacturer Spec%solids % Name-_ Specs on File Specs Submitted Placement Method v Pumped Free Fall Other Seal Completion Complete with Mushroom Cap - __- ft 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. qS MINIMOM X HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS 7 CONTRACTORS SIGNATURE '� TITLE Pe- 5 DATE YOA51hicW ECEtVE _._ _.._. _.. ..............................................._......_..............._......_.__......__. .._. _.................._................- _ _.__.... — _ __._._.........__...__ AN JOAQUIN`COUN lY ENVIRONMENTAL '- — I HEALTH DEPARTMEN .. ,..._. . Hn�.....t. i I .._._............_....... ......._. ......... . _..._........ __....... _..... _._._. ._ ......._._�. ... .....: ...... ...... ..� / y i 6�r t I .-..................... .... ........ ................... .............. ..� iii .. ...._............_,.........._..... _............................._.........._............_.._......_.�__ _...._......._... I : ,DEPARTMENT USE ON Y�7 Application Accepted By t Date [ Area Destruction Inspection By , l Date Lf Employee ID# COMMENTS 1 v''" L• PE SC Received Check Amount Permit/ Date Invoice# Well ID# Codes Info B ash Remitted Service a gest# L4 11--12 g ' - - — EHD 43-08 WELL DESTRUCTION PERMIT 4/30/1'2