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WELL DESTRUCTION PERMIT PUBLIC WATER SYSTEM ❑Yes ❑No n SAN JOAOUIN 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 CITY/ZIP CROSS STREET U APN ! 'VLLJ PARCEL SIZEtLCAND USE APPLICATION# C i OWNER / ( - PHONE n OWNER ADDRESS/ / CITY/STATE/ZIP CONTRACTOR �1c:.1'2, (Yr6 5 5 �w1�N s f p�Z PHONE ?Z'7 - 3/2 O �+ CONTRACTOR ADDRESS O - r✓O�( �� u[ CITY/STATE/ZIP l�i( LCL-/ 7 SL y C-57 WELL DRILLING LICENSE NUMBER { �}lZ3 EXPIRATION DATE ZO LO 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 fi�-Enactive ❑ 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 -_ It below ground surface(bgs) Hole Diameter inches Well Conductor Casing ❑ Yes ❑ No Depth of Conductor Casing It bgs Diameter of Conductor Casing inches Well Casing Diameter _ G _ inches Total Depth _L Z It Depth to Water_ Z S ft Depth of Casing __ It bgs DESTRUCTION SPECIFICATION Sealing Material from It 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 11 Detonating cord EI with projectiles every ft ❑ without projectile ❑ Detonating cord and boosters ❑ with projectiles every _ft ❑ without projectile ❑ Other Sealing Material Neat Cement(94 Ib bag/5-6 gal water) Sand Cement sack mix/7 gal water Bentonite Pellets Bentonite(20%solids) Manufacturer Spec%solids —% Name Specs on File Specs Submitted Placement Method Pumped " Free Fall Other Seal Completion Complete with Mushroom Cap a — 5- 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. MINIMyJU_M- HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS CONTRACTORS SIGNATURE �r��✓///�`✓� " " f TITLE DATE ' I i - I _. __._.,__.. _.. ......._....... . .... ... . ... ......__. .. - ........ _ .__ _ _._ _.._ .... ... ..._ _ .. ......... : - ..__ .. ... . .. _ --- _ ..._. _ .. - - - ..._ ... syy�opj ____ .._. -- I - _ _ I ..................... .................................................................................................... ....... t----.. I............ i DEP RTMENT USE OLY Application Accepted By Date N (Yl Ll Area Destruction Inspection By Date I�� C7� Employee ID# COMMENTS PE SC Received Check#/ Amount Date Permit/ Invoice# Well ID# Codes Info y ash Remitte Service Request# a iy I� k;� CCS EHD 43-0II r( � '(�f � (n WELL DESTRUCTION PERMIT 4/30/12