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WELL DESTRUCTION PERmrr PUBLIC WATER SYSTEM ❑Yesll.I SAN JOAOUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 East Hazelton Avenue-STOCKTON CA 95205 - (209)468-3420 NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED 3 /V. d�11 JOB ADDRESS � ----CITYRIP CROSS STREET r�� /I/G'�! /4 �/ r A P N 7.5 _PARC L SIZE A C•.-��/� elly 37 LAND USE APPLICATION # j OWNER J r h//L–�/ �C� OWNER ADDRESS f =G __ CITY/STATE2IP///� � CONTRACTORK� PHONE_ CON,,,TRIIIACTOR ADDRESS07 CITY/STATE/ZIP 7�! C-57 WELL DRILLING LICENSE NUMBER 111e O _EXPIRATION DATE PERFORATION CONIPAC'TOR PfiONE "7 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_ EXISTINGWELL CONSTRUCTION DETAILS ❑ Open Bottom ❑ Gravel Pack ❑ Uncased ❑ Other Well Log copy attached ❑ Yes ❑ No Grout Seal ❑ No ❑ Yes It below ground surface(bgs) Hole Diameter—, inches Well Conductor Casing ❑ Yes ❑ No Depth of Conductor Casing _It bgs Diameter of Conductor Casing - inches Well Casing Diameter Gj� inches Total Depth/ � It Depth to Water.__Z It Depth of Casing __. it bgs DESTRUCTION SPECIFICATION / / g from _ It bgSIl2ID Sealing Material from ""3 ft bgs to ^� b s Filler Material �- Fl�� s Well casing to be perforated by one of the following methods: _- -from... __ _ It bgs to &C40 ❑ Mills Knife Number of cuts every _ft and/or ❑ Explosives ❑ Detonating cord ❑ with projectiles every It ❑ without projectile C 5 t?02Q ❑ Detonating cord and boosters ❑ with projectiles every ft ❑ without proje>M JO ❑ Other _ _ ENVIRONSCOUNTY Sealing Material Neat Cement(94 Ib bag15-6 gal water) Sand Cement sack mix,7 gal water HEA Atlets Bentonite(20%solids) Manufacturer Spec%solids_ % Name - Specs on File Specs.1unf�r �d Placement Method Pumped Free Fall /Other G 7&5!Seal Completion Complete with Mushroom Cap - -B,oE2,4 g.4(7&/ 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 STAIE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION LAWS. MIN A1"/�4O VANCE NOTICE REQUIRED FOR INSPECTIONS CONTRACTORS SIGNATURE ---------TITLE-,6 DATE ZS Z ...t.._ .... ...... . _ _-. ........... ............. ...._... ._...-.. Me++TAL MALTH WAa WNW j } _ fr` __ IAL PER.I - 1 _. ... 1 r D E R T M ENT USE O Y Application Accepted B __ _ Date jam" Area 3 /% � / Destruction InspectionBy _ ' Date. S /[� --- --_--LEmployee ID# -Foq��'f oL -- COMMENTS V- c t— '(p- a:, /e 5 3 (' ova IV K S t( 3 3 f 41 2oz� (Le4 o 'PL'of') c-t 1e 70, PE SC Received •Check Amount Permit/ odes Info ash Remitted Date Service Request# Invoice# Well ID# b — - D - - 2 [HD 4308 tei iQ� /�/� ( �� WELL DESTRUCTION 11f HMII 4/30/12 7 /9 j'Yl / c�rl�►')an s �/S S 0%��veA S/l ekzo Z.-0