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WELL DESTRUCTION PERMIT <br /> PUBLIC WATER SYSTEM ❑Yes 9)* <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE 3"n FL-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 j . CITY/ZIP <br /> CROSS STREET ��APN r q Say 63 PARCEL SIZE�' LAND USE APPLICATION# C <br /> e <br /> OWNERy� Z�r`� PHONE <br /> w <br /> rn <br /> OWNER ADDRESS �� c CITY/STATE/ZIP t�i� / 1 <br /> CONTRACTOR L�'���/ /`/v !S �'�/in/f—/!/"� ��7' "� PHONE :1` 1-371 <br /> CONTRACTOR ADDRESS hr�1� 9�� �L, 1`�c //�/i7 CITY/STATE/ZIP <br /> ❑ C-57 WELL DRILLING LICENSE NUMBERiEXPIRATION DATE 7 <br /> PERFORATION CONTRACTOR PHONE <br /> PERFORATION CONTRACTOR ADDRESS CITY/STATE/ZIP <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 Expiration 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 A Replacement Well ❑ Caved In ❑ Pit Well ❑ Inactive ❑ Test Hole <br /> Detected/Suspected Well Water Contaminant(s) <br /> Adjacent property with contamination (Address) <br /> Known Soil/Water contaminants at adjacent property <br /> EXISTING WELL CONSTRUCTION DETAILS ❑ Open Bottom ❑ Gravel Pack ❑ Uncased ❑ Other <br /> Well Log copy attached ❑ Yes ❑ No Grout Seal ❑ No ❑ Yes ft below ground surface(bgs) Hole Diameter inches <br /> Well Conductor Casing ❑ Yes ❑ No De // nductor Casing ft bgs ,� Diameter of Conductor Casing inches <br /> Wt Well Casing Diameter inches T0191 ft Depth to Water �fl- Depth of Casing ft bgs <br /> DESTRUCTION SPECIFICATION <br /> Sealing Material from ft bgs to It bgs Filler Material from ft bgs to ft bgs <br /> Well casing to be perforated by one of the following methods: from ft bgs to ft bgs <br /> ❑ Mills Knife Number of cuts every ft and/or <br /> ❑ Explosives ❑ Detonating cord ❑ with projectiles everyft ❑ without projectile <br /> ❑ Detonating cord and boosters ❑ with projectiles every ft ❑ without projectile <br /> ❑ Other <br /> Sealing Material ❑ Neat Cement(94 lb hag/5-6 gal wafer) ❑ Sand Cement sack mix/7 gal water Bentonite Pellets <br /> ❑ Bentonite(20%solids) ❑ Manufacturer Spec%solids % Namc ❑ Specs on File ❑ Specs Submitted <br /> Placement Method ❑ Pumped ❑ Free Fall ❑ Other <br /> Seal CompletionComplete with Mushroom Cap f ft 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. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> DVANyyC��EE,NOTICE REQUIRED FOR INSPECTIONS / <br /> CONTRACTORS SIGNATURE TITLE� DATE <br /> 41 r <br /> 1 r <br /> 1,1111 <br /> DEPARTMENT USE 4 <br /> RQ le <br /> ' u <br /> DEPARTMENT USE ONL ���/ � 04?0� <br /> Application Accepted By Date 5 Z aZc� Area11 <br /> r7a '111C -Ir <br /> Destruction Inspection By 1' 1 Date T Employee ID# p <br /> COMMENTS 7Ae Irl �LYIDr o vl� irr LI 1 r e P �iri"111� t° ih DbSfiuC�do�1S w�,6h <br /> with eFJ'iiv Fra ( PeI26 -r 1,4011 =iz 6- IC.Abim1 fr >✓)�-h <br /> f- Ry Mk <br /> PE Sc Received Chec Amount Permit/ <br /> Codes Info B Cash Remitted Date Service Request# Invoice# Well ID# <br /> N368 <br /> EHD 43-02-008 Well Destruction Permit <br /> 1/27/2005 <br />