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WELL DESTRUCTION PERMIT PUBLIC WATER SYSTEM ❑Yes SAN JOAQUIN 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 JOB ADDRESS y!�/!�/, dJ� CITY/ZIP ��1.%/t��1 l f:zj� Tr Z T y CROSS STREET APN C>(I t 3 Lkr,k i PARCEL SIZEAI;' AND USE APPLICATION# OWNER h �1G��C /�/` �/�S _PHONE t-121- J�!—/A1O + C z OWNER ADDRESS_ Sj�r CITY/STATE/ZIP I-I P4 `,w GlTt CONTRACTOR �J� ivy �} PHONE CONTRACTOR ADDRESS IG4/ { _ CITY/STATE/ZIP ❑ C-57 WELL DRILLING LICENSE NUMBER EXPIRATION DATE PERFORATION CONTRACTOR PHONE 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 XDry ❑ 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 EXISTING WELL CONSTRUCTION DETAILS r Open Bottom ❑ Gravel Pack ❑ Uncased ❑ Other Well Log copy attached ❑ Yes ❑ No Grout Seal ❑ No ❑ Yes ft below ground surface(bgs) Hole Diameter..___ _ inches Well Conductor Casing ❑ Yes ❑ No Depth of Conductor Casing _ ft bgs Diameter of Conductor Casing.- _ inches Well Casing Diameter _T__inches Total Depth 35.ft Depth to Water1� ^ft Depth of Casing _ ft bgs DESTRUCTION SPECIFICATION Sealing Material from ft bgs to ft bys Filler Material from ft bgs to ft bgs Well casing to be perforated by one of the following methods: _ _ __ from ft bgs to ft bgs ❑ Mills Knife Number of cuts every ____________-_ft and/or ❑ Explosives ❑ Detonating cord ❑ with projectiles every _ _ ft ❑ without projectile ❑ Detonating cord and boosters ❑ with projectiles every ft ❑ without projectile ❑ Other Sealing Material Neat Cement(94 lb bag/5-6 gal water)Sand Cement �:7 sack mix17 gal water Bentonite Pellets Bentonite(20%solids) Manufacturer Spec%solids___ O� Name Specs on File Specs Submitted Placement Method Pumped Free Fall Other !r � )50-IV;42 vir--> Seal Completion Complete with Mushroom Cap ft bgs >4 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 STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION LAWS. H VANCE NOTICE REQUIRED FOR INSPECTIONS CONTRACTORS SIGNATURE f TITLE L�/�//K� DATE ._ .... ..............._.__...... ._ _'.. y ..p. ........ _ _.. _ _.- ___ - _ ....... P . ..... C f� 2>11 ............-..._... ...._. O�A�(4_ �N�oA ,A U�N � 7Y __......._ _. �__- -• (t/�; I� •'' ..-`�`-' as • D E P A R T M E N T U S E O N L Y Application Accepted By Date 3 u��l Area Destruction Inspection By. Datet3 ?ilEmployee ID# d COMMENTS w ' <,l� .� � w y` U 1 �. A. !LJ4 PE SC ReceivedChe Amount Date Permit/ Invoice# Well ID# Codes Info B ash Remitted, Service Request# 31 is ` _> EHD 43-08 WELL DESTRUCTION PERMIT 4/30/12