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WELL DESTRUCTION PERMIT PUBLIC WATER SYSTEM ❑Yes ❑No SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPT 1868 East Hazelton Avenue-STOCK70N CA 95205-6232-(209)468.3420 NON-REFUNDABLE PERMIT CALL(209)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS �T(�O n t•'�U'L CITV/LP L.� CROSS STREET_. `" �' l `� APN 'l`O - 1 ill- PARCEL erS�SIZE r(�`S LAND USEAPPLICATION OWNER_ � .a\W"i IfO r r' 1PHONE aI-0 i- EN b 1 - Ii("II, D"�, OWNER ADDRESS 7 3 �r� Z\ Pr '7t'\1 CITYISTATE/ZIP^�0.tJ CONTRACTOR .t/' a ,(`• \r N! L \ i0 PHONE S`1 /9 .. /' CONTRACTOR ADDRESS -101=` (�� Q Cn YISTATEIZIP I V e-I G JL CA "1?• "s C-57 WELL DRILLING LICENSE NUMBER ,- EXPIRATION DATE_ PERFORATION CONTRACTOR PHONE PERFORATION CONTRACTOR ADDRESS CITYISTATE/ZIP 4B�C-57 Well Drilling License Number � Expiration Date 5-:31,) 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 Shenff-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 i❑ Inactive ❑ Test Hole Detected/Suspected Well Water Contaminants) J� Adjacent property with contamination(Address) Known Soil/`Nater contaminants at adjacent property EXISTING WELL CONSTRUCTION DETAILS ❑ Open Bo.tom 7 Gravel Pack O Urcased ❑ Other Well Log copy attached ❑ Yes ❑ No Grout Seal ❑ N.; ❑ Yes___,__ft below ground surface(bgs) Hole Diameter bleflss Well Conductor Casing❑ Yes ❑ No Depth of Conductor Casing ft bgs Diameter of Conductor Casing btdtes Well Casing Diameter r Inches Total Depth _It Depth to Water It Depth of Casing R bgs DFITRI CTIPN'PECIFIr'�TjoN ,�AA�.� 1 Sealing Material from V _ft cgs to_��ft bgs Filler Material ( Y l l from © R bgs to �6 ft bgs Well casing to be perforated by one of the following methods: from ft bgs to R bgs ❑ Mills Knife Number of cuts every ft and/or ❑ Explosives❑ Detonating cord ❑ with projectiles every ft ❑ without projectile P ❑ Detonating cord and boosters ❑ With projectiles every ft ❑ without projectile A A YM l r Cl Other_ _ __ .IJ`ECEI Sealing Material Neat Cement(941b beg/5-6 gal water) Sand Cement sack mix'7 gal water Bentonite Peliats V ED Bentonite(20'/,solids) Manufacturer Spec%soiWs-Q-0 9; Name W A Z Specs on File Specs Submitted Placement Method Pum• dFree Far 9 y (Other d� Seal Completion Complete with Mushroom Cap Ccmptete:o Existing S-Iace Pad n 8 �O�O I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH §WN JQ JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENS LsENVIgQUiNC CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH Lr RCNIl7j;N COU WORKERS COMPENSATION LAWS. N DEP'q'R '4 L T M IMU 4 UR NCE NOTICE REQUIRED FOR INSPECTIONS CONTRACTORS SIGNATURE TITLE S V QJ 14 S:)Y- DATE t 1\ y --+— uy 4, -------- I=A�tl ---• rtv .�J ty W ti I I 1 � a- 14%ase' DEPARTMENT USE O LY Application Accepted By Date 618 k'ZV Area /t iGl ,CUt Destruction Inspection By 11� Date 5 Z Employee/6 7A COMMENTS he In f /1 f YI rl G i/' G a n. obstlgCtlon5 which mirhh 'll rile+fere h e reo'l Stalin l r IL5r J)ppth gf rje1l 9n-j oyn ePer e46'AAy 'r a7,05- e_=)iI 1�C�Vp*-JaO eit be'li ,r/ Cfoc,» ct,firatp If C/Preer 'Ird itki PE Sc Received Cheeldl Amount Permit/ Codes Info By Cash Remitted Dab Service Ra uest s Invoice>f Wall M P?5r wP00q62 76 EHD CC/� WELL DESTRUCTION PERMIT revised d 411 4!14!78