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WELL DESTRUCTION PERMIT <br /> PUBLIC WATER SYSTEM ❑Yes ❑No <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE 3-FL-STOCKTON CA 95202 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL(209)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> C � <br /> JOB ADDRESS �• a. Il /Z <br /> CITYIP <br /> D <br /> c o <br /> CROSS STREET S APN�� aL i.-�s7 PARCEL SIZE AND USE APPLICATION ti p <br /> r ^ <br /> OWNER 38 �J-C r PHONE y <br /> OWNERADDRESS Z CITY/STATE/ZIP_.)1/i, <br /> CONTRACTOR J-J <br /> f PHONE 2 <br /> CONTRACTOR ADDRESS / .QN / p CITY/STATE/ZIP <br /> C-57 WELL DRILLING LICENSE NUMBEREXPIRATION DATE_ ';;!w � <br /> PERFORATION CONTRACTOR PHONE <br /> PERFORATION CONTRACTOR ADDRESS CITY/STATE/ZIP <br /> ❑ C-57 Well Drilling License Number Expiration Dale <br /> ❑ Bureau of Alcohol,Tobacco and Firearms-Users of High Explosives License Number Expiration Date <br /> ❑ CHP Hazardous Material Transportation for Explosives License Number Expiration Date 1 <br /> ❑ San Joaquin County Sheriff-Comner Explosives Application and Permit License Number Expiration Date <br /> ❑ California Occupational Safety Health-Blaster License Number Expiration Date <br /> REASON FOR DESTRUCTION ❑ Dry ❑ Replacement Well XICaved In ❑ -Pit Well ❑ Inactive ❑ Test Hole <br /> Detected/Suspected Well Water Contsminaat(s) <br /> Adjacent property with contamination(Address) <br /> Known Soil/Water contaminants at adjacent propeny <br /> EXISTING WELL CONSTRUCTION DETAILS ❑ Open Bottom I 1 Gravel Pack ❑ Uncased ❑ Other <br /> Well Log copy attached ❑ Yes J2 SNo Grout Seal ❑ No ❑ Yes ft below ground surface(bgs) Hole Diameter inches <br /> Well Conductor Casing ❑ Yes ❑ No Depth of Conductor Cuing ft bgs Diameter of Conductor Casing inches <br /> Well Casing Diameter inches Tohl Depth���ft Depth to Water�,�_ H Depth of Casing ft bgs <br /> DESTRUCTION SPECIFICATION <br /> Sealing Material from ft bgs to R bgs Filler Material from /4,6, it bgs to f' ft bgs <br /> Well casing to be perforated by one of the following methods: from R bgs to ft bgs <br /> ❑ Mills Knife Number of curs every ft and/or <br /> ❑ Explosives ❑ Detonating cord ❑ with projectiles everyR ❑ without projectile <br /> ❑ Detonating cord and boosters ❑ with projectiles everyft ❑ without projectile <br /> ❑ Other <br /> Sealing Material ❑ Neat Cement(94 lb bag/3-6 gal water) ❑ Sand Cement sack mix/7 gal water Bentonite Pellets <br /> ❑ Bentonite(20%wilds) ❑ Manufacturer Spec%solids_% Name ❑ Specs on File Specs Submitted <br /> Placement Method❑ Pumped N 'Free Fall ❑ cher <br /> Seal Completion :;W,Complete with Mushroompletc to Existing Surfa <br /> Cap R bgs k Comce Pad <br /> 1 HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS. 1 ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT 1 AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> MIN It IMUM�f24 HOU <br /> nR/1ADVANCE NOTICE REQUIRED\FOR <br /> �INSPECTIONS DATE I]19 <br /> CONTRACTORS SIGNATURE 1 F /�'//L,d f.h� TITLE1J�y(L:'` •- �� <br /> r? CE!VFL <br /> U)'* AUG 3 0 ZU01J <br /> © �tJutip SAN JOAQUIN GOUNTY <br /> 71�!! ENVIRONMENTAL <br /> `Ij+ !� HEALTH DEPARTMENT <br /> -- -- --D-E -T Area 5-E--O N L Y -_ ---— - -- <br /> t �f0,t1 V V <br /> Application Accepted By Date <br /> Destruction Inspection By �-t t n Date a '.i cc Employee IDM <br /> COMMENTS 10 - / <br /> i <br /> PE SC Received Cha Amount Date Permit/ Invoice M Well IDM <br /> Codes Info B Cash Remitted Servlee R uest M <br /> tA s CiO.Oo <br /> W01 D.,rucr—Pmnit <br /> EHD 43-02-008 <br /> IR7Ra05 <br />