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WELL DESTRUCTION PERMIT PUBLIC WATER SYSTEM ❑Yes_2 No SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPT 1868 East Hazelton Avenue-STOCKTON CA 95205-6232 -(209)468-3420 NON-REFUNDABLE tPERMIT , t Cr'- CALL f209)95`3-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS 7,-•0 W` CT " 1 K C. �P. CITY/ZIP ��] h L 5 310 I CROSSSTREET E^S� �TCQt,S ME AN APN ��86DOG) PARCEL SIZE J LAND SE APPLICATION J 1�O DODO Ct OWNER �O(��w ` (O moI LL L PHONE "O —('�+I4 (J 1 p OWNER ADDRESS '\O ; VL /` CITY/STATE/ZIP ` I(-o� A( 0S J O CONTRACTOR r t 1 1 G (-PHONE a Y- 6 61 - -2 -5.9L 11 CONTRACTOR ADDRESS 3 0 o r 0 CITY/STATE/ZIP_ 1 C V r liD Ji— )tL1A 1 J�{O C-57 WELL DRILLING LICENSE NUMBER per` u EXPIRATION DATE PERFORATION CONTRACTOR PHONE PERFORATION CONTRACTOR ADDRESS CITY/STATE(ZIP ❑ C-57 Well Drilling License NUmDer 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 Zinactive ❑ Test Hole Detecteo r 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 ❑ Other Well Log copy attacr.ec ❑ Yes liff No Grout Seal ❑ No III Yes 100 ft below ground surface(Dgs) Hole Diameter 110 inches Well Conductor Casing❑ Yes a No Depth of Conductor Casing ft togs Diameter of Conductor Casing inches Well Casing Diameter s TT inches Total Depth ft Depth to Water J( ft Depth of Casing ft bgs DFITRI CTII1♦SPF CIFIC ATTON Sealing Material from ft togs to _ f;togs Filler Material from ft logs to ft bgs w` Well casing to be perforated by one of the following methods: from ft bgs to ft logs H YM/►� ❑ Mills Knife _ ___Number of cuts every ft and/or ��NeAIT ❑ Explosives❑ Detonating cord ❑ with projectiles every ft ❑ without projectile /� i�6 ❑ Detonating cord and boosters ❑ with projectiles every ft ❑ without projectile Y ❑ Other p Sealin Material Neat Cement(94 lb bag 15-6 gal water) Sand Cement-�—sack mix/7 g�S:pecs Bentonite Pellets �1 Bentonite(20%solids nufacturer Spec%solids-3+O % Name W��p t-N QF n File Soecs Su"W1 G/ Placement Method Pumpe Free F I�1 �J%.%/ Other IV,f Seal Completion Compl us hroom Cap—�{r� Ajt'tgs Complete to Existing Surface Pad HE EN �RO� C pUNTy HEREBY CERTIFY THATI ED IS JOAQUIN COUNTY ORDINANCES,STATE LAWS HAND RULES A DIONAND RGULATIONS.THAT THE WORK SO(CERT FYLL BE DOTHATNE NMYCREQUIREDELICENSE WITH AIS �(;Pq Tn'1ENT CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION LAWS. HOUR VANCE NOTICE REQUIRED FOR INSPECTIONS (� CONTRACTORS SIGNATURE TITLE S V 90Q{U r 50 r DATE A no,Y- o 1 l I.jlTl. - .1. 1 I -int r_ t FoV 5 � I L7 / DEPARTMENT USE ONLY Application Accepted By t� �� It Date 4/13/202 Area 5/Tracy Destruction Inspection By, c— N Date ZG ZO Employee ID# DA COMMENTS The interior of the casing shall first be cleared to eliminate any obstructions which might interfere with effective sealing procedures. PE SC Received Check#/ Amount Date Permit/ Invoice# Well ID# Codes Info B Cash Remitted Service Re uest# 4373 161 LAL EHD 43-08 WELL DESTRUCTION PERMIT revised 4/14118