WP0040407 - Laserfiche WebLink

Home Browse Search

WELL DESTRUCTION PERMIT PUBLIC WATER SYSTEM ❑Yes ❑No SAN JOAQUIN 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 / r JOB ADDRESS S C CITY/ZIP /� Y CROSS STREET U APN V/ PARCEL SIZE AND USE APPLICATION# F OWNER PHONE s 'n OWNER ADDRESS //,, CITY/STATE/ZIP '' CONTRACTOR �h n 6 S f !N-c l'I iL PHONE / a� CONTRACTOR ADDRESS lf6 JL- d5- CITY/STATE/ZIP lie C-57 WELL DRILLING LICENSE NUMBER 46"M17-3 EXPIRATION DATE Z 6 L0 PERFORATION CONTRACTOR PHONE PERFORATION CONTRACTOR ADDRESS CITY/STATE/ZIP O 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 AL 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 Bottorn ❑ 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 inches Total Depth _ It Depth to Water_It Depth of Casing It bgs DESTRUCTION SPECIFICATION r 7 Q Sealing Material frorn j2— it bgs to _ O I 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 ❑ Detonating cord and boosters ❑ with projectiles every ft ❑ without projectile ❑ Other Sealing Material Neat Cement(94 lb bag/5-6 gal water) Sand Cement - _sack mix/7 gal water OC Bentonite Pellets Bentonite(20%solids) Manufacturer Spec%solids % Name L. 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. MIN UM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS CONTRACTORS SIGNATURE TITLE elll_ �i lir DATE Z �� __....�_.__.. ..............._......_............... . .. _ ___. t i } .. ... .... . :...._................... qNJ0 FNS AQP/N _ � a T/R�NM ��VN .._............ .. L _ ..__.. __ ....__.. .._._.... __?_ _ _ _ _ ---......._._-._........_...._. ..._............_............_.....-__....._..._..._... i D� A R T M E N T U S E O N L Y',{ Application Accepted By Date W Area _ Destruction Inspection By ' _ Date �� (2A'2.- Employee ID# COMMENTS PE SC Received Check#/ Amount Date Permit Invoice# Well ID# Codes Info B Cash Remitted mrviceRe uest# 3 6 1 2 I I-Im 4.13 08 \o2�2b WELL DESTRUCTION PERMIT