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F1V�ELL DESTRUCTION PER14 <br /> PUBLIC WATER SYSTEM [I Yes No <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE 38"FLOOR-STOCKTON CA 95202 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL(209)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS r CITY/ZIP <br /> L�C.h�JC2JKI- D7 m <br /> OWNER - t PHONE�\1 `9.J;�— qgj Ipo <br /> OWNERADDRESS .. IF-�L b10f-aP6 S'f CITY/STATE/ZIPQY�`l• <br /> CONTRACTOR � �.4. /pL��F/, ���" ttN�� PHONE (/ — - J7 y <br /> CONTRACTOR ADDRESS �fC S/' �'I 11 CITY/STATEIZIP �+` <br /> 0. C-57 WELL DRILLING LICENSE NUMBER I �Y . 77 EXPIRATION DATE <br /> PERFORATION CONTRACTOR _iTJl1 FT 1 T_ PHONE <br /> PERFORATION CONTRACTOR ADDRESS CITY/STATE/ZIP <br /> xu C-57 Well Drilling License Number Expiration Date <br /> Bureau of Alcohol,Tobacco and Firearms-Users of High Explosives License Number �!it41g� Expiration Date <br /> CHP Hazardous Material Transportation for Explosives License Number Expiration Date <br /> ❑ San Joaquin County Sheriff-Coroner Explosives Application and Permit License Number Expiration Date <br /> California Occupational Safety Health-Blaster License Number " t o Expiration Date 1 I ` 3 <br /> REASON FOR DESTRUCTION ❑ Dry ❑ Replacement Well ❑ Caved In ❑ Pit Well Inactive ❑ Test Ilole <br /> Detected/Suspected Well Water Contaminant(s): 0�5 <br /> Adjacent property with contamination (Address): <br /> Known Soil/Water contaminants at adjacent property: <br /> EXISTING WELT.CONSTRUCTION DETAILS ❑ Open Bottom ,0 Gravel Pack ❑ Uncased ❑ Other <br /> Well Log copy attached ❑ Yes M No Grout Seal Q No ❑ Yes Il below ground surface(bgs) Hole Diameter 77 <br /> if inches <br /> Well Conductor Casing ❑ Yes 0 No Depth of Conductor Casing A bgs Diameter of Conductor CasinLinches <br /> Well Casing Diameter _inches Total Depth 111214" it Depth to Water ft Depth of Casing t tl bgs <br /> DESTRUCTION SPECIFICATION r� 1 <br /> Sealing Material from ,3 ft bgs to�!� 41Y ft bgs Filler Materiald "J -5/M1M dJ6 r fl bgs m 111214"' n bgs <br /> Well casing to be perforated by one of the following methods from ti bgs to 112 ft bgs <br /> ❑ Mills Knife Number of cuts every ft and/or <br /> Explosives ❑ Detonatingeord: ❑ with projectiles every ft ❑ without projectile <br /> Detonating cord and boosters: E3with projectiles every t 5--ft 11without projectile <br /> ❑ Other <br /> Sealing Material ❑ Neat Cement(94 lb bag/5-6 gal water) XSandCement 1<p.'�j sack mix/7 gal water ❑ Bentonite Pellets <br /> ❑ Bentonite(20%solids) ❑ Manufacturer Spm%solids % Name El SpecsonFile ElSpecs Submitted <br /> Placement Method ❑ Pumped ❑ Free Fall ❑ Other <br /> Seal Completion: Complete with Mushroom Cap ! ti bgs ❑ Complete to Existing Surface 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 /> MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br /> ,/: I TITLE .,. DATE: <br /> , CONTRACTORS SIGNATURE:r 1 �'� N 5 <br /> I <br /> I I <br /> )INLJ t-�• <br /> � <br /> rMENti� n T Y <br /> _ 9 2op4 <br /> p��( 1 <br /> O F 7Je Z. ,,VE N JOPOOINr w,l <br /> L' 00 <br /> 7 SH 0IPP TpjEN <br /> l DEPARTMENT USE ONLY <br /> Application Acceptedl'By ' / tG� �i � '/�'�"�—��'� Date I/� Area <br /> Destruction lnspectioN_ arwDate a Employee ID# O.J <br /> COMMENTS <br /> PE SC Received Check#/ Amount Permit/ <br /> Codes Info B Zash Remitted Date Service Request# Invoice# WeI11D# <br /> 37 ' h. �oacYl o1a4/871 <br /> EHD 43-02-0M <br /> (VI'" Wcll Demuoion Permit Add ndum 4604 Ic 6-N-04 <br /> fikeek 4o Mas 1` A-KKe-rz- 01 (o) Skl-b`130 1,— C <br />