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WELL DESTRUCTION PERMIT <br /> PUBIJC WATER SYSTEM 0 Yes ❑No <br /> SAI.JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPT 1868 East Hazelton Avenue-STOCKTON CA 95205-6232-(209)46&3420 <br /> NON-REFUNDABLE PERMIT ALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> Joe ADDRESS__ <br /> aTr2P <br /> CROSS STREET/� O t/�/� /l.'-A,?c PARCEL SRE,D LA^�ND USE APPLICATION# O <br /> OWNER / 1 / 4 L� 7 L PHONE OG` L SS <br /> D //b/ <br /> OWNER ADDRESS G <br /> cCITY/STATFJZIPC �� L L(�// cA,,CL- <br /> COTRACTTOOR (f PHONE Y G/ — 7 UC <br /> CONTR ADDRESS CITYISTATE/ZP/') �-r <br /> e-l-c ecl dna— <br /> C-57 WELL DRILLING LICENSE NUMBER (6) -"T EXPIRATION DATE / r)- <br /> PERFORATION CONTRACTOR PHONE <br /> PERFORATION CONTRACTOR ADDRESS aTY/STATEIZIP <br /> ❑ C-57 Well Drilling License Number Expiration Date <br /> Bureau of Alcohol.Tobacco and Firearms-Users of High Explosives License Number Expiration Date <br /> CHP Hazardous Material Transportation for Explosives License Number Expration Date <br /> San Joaquin County Sheriff-Coroner Explosives Application and Permit License Number Expiration Date <br /> California Occupational Safety Health-Blaster License Number Expiration Date <br /> REASON FOR DESTRUCTION ❑ Dry ❑ Replacemept veil ❑ (}�yv��d In ❑ PR Well Inactive ❑ Test Hole <br /> Detected I Suspected Well Water Contaminant(s) N [-/� G'-) <br /> Adjacent property with contamination(Address) �4! <br /> Known Soil/`,Nater contaminants at adjacent property <br /> Exls'TING WELL CONSTRUCTION DETpi )I�Open Bottom ❑ Gravel­ k ❑ Uncased ❑ Other <br /> Well Log copy attached ❑ Yes No Grout Seal ❑ No fes n below ground surtace(bgs) Hole Diameter inches <br /> Well Conductor Casing❑ Yes No Depth of Conductor Casing N44 it bgs Diameter of Conductor Casing y _1:inches <br /> Well Casing Diameter _inches Total Depth .�ft Depth to Water _30 it Depth of Casing R bgs <br /> DE..SERLCHOY$PECIFTCATIOY <br /> Sealing Material from 7 _ft bgs to (} _ it bgs Filler Material __ _ __from_ _ R bgs to _ _ft bgs <br /> Weil casing to be perforated by one of the followi.q methods, from -ft bgs to ft bgs <br /> Mills Knife Numberof cuts every Rand/or <br /> ❑ Explosives❑ Detonating cord ❑ with projectiles every _ R ❑ without projectile MC� <br /> ❑ Detonating cord and boosters ❑ with projectiles every ft ❑ without projectile <br /> ❑ Other VFD <br /> Sealing Material Neat cement(94/b bag/5-6 gal:vats-) Sand Cement /Cr S sack ma 17 gal water Bentonite Pell <br /> Bentonite(20%solids) facturer Spec%solids_% Name __ Specs on File Specs SubmittO <br /> Placement Method Pum Free FAll SU`-0 4tler 6 `2020 <br /> Seal Completion Complete with R Mushroom Cap �' �0 bgs Complete to Existing Surface Pad .Sq <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE '-' <br /> UIN <br /> JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIREDgpNI19ENTUNTy <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL�EPgRTMENT <br /> WORKERS COMPENSATION LAWS. <br /> N11t •1U111 49 HOUR A VANCE f40TICE REQUIRED FOR INSPECTIONS <br /> CONTRACTORS SIGNATU L{•yO �T� D(�n�� DATE . <br /> r�-G �G ` <br /> l <br /> -1 L <br /> , <br /> I , <br /> I i <br /> I <br /> -'-i--t--' --rt— <br /> frt - <br /> i ) <br /> y� DEPARTMENT USE ON5! <br /> Application Acoepted By !__ �� Date ZdZ <br /> n^ Area <br /> Destruction Inspection By Date f o� Employee lD# <br /> COMMENTS WQ. C U 6) A wF h 11 3 s <br /> r <br /> PE tsC *PhomteNoed Check#1 Amount D Permitl <br /> Cod- �IlbCash Remitted Service Request# Invoice Well ID# <br /> 4373 /6 <br /> EHD 4308 <br /> revised 4/14/18 /,b71G7937 WELL DESTRUCTION PERMIT <br />