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WELL DESTRUCTION PERMIT } PUBLIC WATER SYSTEM ❑Yes ❑No T SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPT 1868 East Hazelton Avenue-STOCKTON CA 95205-6232-(209)465-3420 NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECT!, EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS CITY2IP p1 2 CROSS STREET 4- c APN�J-ZZrO- ZS PARCEL SIZE 4( LAND USSEI APPLICATION# OWNER 11 QQ• G 1�✓ i and PHONE J ✓LQ i ^ OWNER ADDi91 OO E . 1 V C7 —CITY/STATE/ZIP Lt Ch �L�� CONTRACTOR �}G1�4;Y1!% lbraS S. O r i Zl�A!q to . PHONE -1 - `I. V 1.� CONTRACTOR ADDRESS%a3 La. CITY/STATE2IP LS Pr �J C-57 WELL DRILLING LICENSE NUMBER �1� 1 EXPIRATION DATE C5— ^' PERFORATION CONTRACTOR PHONE PERFORATION CONTRACTOR ADDRESS - CITYISTATE21 r IC-57 Well Drilling License Number �O Expiration Date 6'yi 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 O 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 ❑ 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 inches Total Deptht, (v� ft Depth to Water It Depth of Casing _ ft bgs DESTRUCTION SPE(IFR ATION �vv Sealing Material from �,Q'0 ft bgs to J It 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 ❑ Detonating cord and boosters ❑ with projectiles every ft ❑ without projectile ❑ Other Sealing Material Neat Cement(94 lb beg/5-6 gal wafer) Sand Cement sack mix/7 gal water Bentonite Pellets XBentonite(20%solids) Manufacturer Spec%solids % Name Specs on File Specs Submitted Placement Method Pumped Free Fall Other Seal Completion Complete with Mushroom Cap_ ft bgs 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. MINIMUM 24 HOUR ADVANCE NOTICE REOW ` INSPECTIONFl CONTRACTORS SIGNATURE LE V • �� DATE :I - 44 M � —; - - - 0"ICin - - - SAC, H FNS/ QU)N C F'4CTy �ART�CNS — — — — MFNT i I t I i t DEPARTMENT USEON Y Application Accepted ey G �/ Date Lv Area C Destruction Inspection By Date Employee ID# SK COMMENTS b! PE SC Received eck#I Amount PermiU Codes Info Date Remitted Service Request# Invoice# Well IDN i7r3 5-11 Zt7 EHD 43-08 WELL DESTRUCTION PERMIT 1015/07