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WELL DESTRUCTION PERMIT PUBLIC WATER SYSTEM ❑Yes ❑No SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPT 1868 East Hazelton Avenue-STOCKTON CA 95205-6232-(209)468-3420 NON-REFUNDABLE PERMIT C -CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS �( ^ 1_o w e -S {ANI Cm/Z" L C4- '-1 9 5 LM CROSSSTREET I\'L- 1{ �C� Lt '�'- AP -(N G• 7-1 IC CI PARCEL SIZE ND USE APPLICATION# 1 � OWNER ,e n n t'}" 7Lu q-�I7PHONE +L 'I� /+ OWNERADDRESS S V )`7 G 4 I -1 / CITYISTATE/ZIP t Lc. 1 t C �� l III CONTRACTOR { ' PHONE L�/✓rl CONTRACTOR ADDRESS Y�f-�U ICz, `"I 7 CITY/STATE/ZIP �71 �C C-57 WELL DRILLING LICENSE NUMBER -7 L19 3 EXPIRATION DATE / - -2L 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 ❑ Dry ❑ Replacement Well ❑ Caved In ❑ Pit Well ;ML Inactive ❑ Test Hole Detected/Suspected Well Water Contaminants) Adjacent property With contamination(Address) Known Soil/Water contaminants at adjacent property EXISTING WELL CONSTRUCTION D %4,Open Bottom ❑ Gravel Pack ❑ Uncased ❑ Other_ Well Log copy attached ❑ Yes T .No Grout Seal *No ❑ Yes_ _ ft below ground surface logs) Hole Diameter_ inches Well Conductor Casing❑ Yes 51,No Depth of Conductor Casing ft bgs Diameter of Conductor Casing inches Well Casing Dlameter___S. __inches Total Depth QOG It Depth to Water? ft Depth of Casing_�ft bgs DEST'RUCPION SPE(IFI(ATION Sealing Material from4"ISR bgs to � ft bgs 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 A�jW ❑ Detonating Cord and boosters ❑ with projectiles every ft ❑ without projectile ev ❑ Other Fe Sealing Material Neat Cement(941b bag/5-6 gal water) � Sand Cement ks_� sack mix/7 gal water Bentonite Pellets e,V� Bentonite(20%solids) Manufacturer Spec%solids % Name Specs on File Specs Submitted Placement Method Pumped Free Fall Other L7 Seal Completion Complete With Mushroom Cap 5 ft bgs Complete to Existing Surface Pad 0j ®z ZO�n 1 HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SA �OgQU/ U JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICEN NV/ N C CURRENT AND ACTIVE WITH WORKERS COMPENSATION LAWS. -'PA CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH LTH PAR . ue MINIMUM 48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS CONTRACTORS SIGNATURE /OLS// r�i�72"` TITLEy ICC I Ct'J DATE W _ C C � I '1 14SU K � le'Jlgn V)C DEPARTMENT USE ONLY �� a Application Accepted By �� Date Destruction Inspection By Date Employee ID# COMMENTS 141tl V, IVfLL- !S E 't v' 6 ill F- PE SC Received Check#/ Amount Date Permit/ Invoice# Well ID# Codes Info Remitted Service Request# k4 12 L I EHD 43-08 WELL DESTRUCTION PERMIT revised 4/14/18