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WELL DESTRUCTION PERMIT <br /> PUBLIC WATER SYSTEM ❑Yes ❑No <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 East Hazelton Avenue-STOCKTON CA 95205-(209)468-3420 <br /> NON-REFUNDABLE PERRJMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED r <br /> JOB ADDRESS 2Z J �1 CRYRIP I�{ I �" <br /> CROSS �11 KIM <br /> STRI?E7 /I p APN 24�_�JU PARCEL SIZE(J�LIAjN�D USE APPLICATION E <br /> OWNER ''JJ " r !fes PHONE <br /> OWNER ADDRESS Zr"�J-I tri 41� CITOSTATE/LP 7-2- <br /> CONTRACT <br /> 7 <br /> CONTRACTOR r G PHONE "JZ <br /> CONTRACTOR ADORESS—fl-q- II jE &_t// CnY/8TA7E/Z1PJ� 'J, I <br /> C-57 WELL DRILLING LICENSE NUMBER IIl'O/}�047— EXPIRATION DATE !1 <br /> PERFORATION CONTRACTOR PHONE <br /> PERFORATION CONTRACTOR ADDRESS Crrv/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 ❑ Replacement Well ❑ Caved In ❑ Pit Well ❑ Inactive ❑ Test Hole <br /> Detected/Suspected Well Wet r ontaminanl(s) <br /> Adjacent property with contamination(Address) <br /> Known SoiVWaler contaminants at adjacent property__ <br /> EXISTING WELL CONSTRUCTION DETAILS ❑ Open Bottom Gravel Pack ❑ Uncased ❑ Other <br /> Well Log copy attached ❑ Yes �No Grout Seel ❑ No ❑ Yes_ It below ground surface(bgs) Hole Diameter inches <br /> Well Conductor Casing❑ Yes No Depth of Conductor Casing It bosr Diameter of Conductor Casing___..—_inches <br /> Well Casing Dlameter_�inches Total Depth_q0L_if Depth to Water it Depth of Casing It bgs <br /> ESTR TI NP IFI ATI I <br /> Sealing Material from it 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 it bgs to_ it bgs <br /> ❑ Mills Knife Number of cuts every it ancVor <br /> ❑ Explosives❑ Detonating cord ❑ with projectiles every It ❑ without projectile <br /> ❑ Detonating cord and boosters ❑ with projectiles every It ❑ without projectile <br /> ❑ other <br /> S alt g Material Neat Cement(94 Ib bag/5-6 gal water) Send Cement _ sack mix/1 gal water - Bentonite Pellets <br /> Bentonite(207 s I'd Manufacturer Spec°b solids % Name_ _ Specs on File Specs Submitted <br /> PI ement Metho Pumped Free Fall I Other <br /> Seal Completion omplate with Mushroom Cap _ ft bgs Complete to Existing Surface Ped <br /> I HEREBY CERTIFY THAT I 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 /> W <br /> MIN UR 4NPYANCE NOTICE REQUIRE FOR INSP CTIONS�p <br /> CONTRACTORS StONATURB TITLEr N �I' UATElP <br /> - - C SENT <br /> QED <br /> 3 2020 <br /> - AREA �TA�TY <br /> j - - MENT <br /> DEPARTMENT USE ONLY <br /> Application Accepted By A2— Date 6 30 � t. (C <br /> Area <br /> Destruction Inspection By D. Z D-'v ERtployae DS —<A <br /> _-- <br /> COMMENTS <br /> PE SC Received Check#/ Amount Date Permit/ Invoice N Wall IDI/ <br /> Codes Into B Cash Remittedrvice R ues if <br /> 43 s,t ot;v its 1 ) <br /> EHD 43-08 ( / 1162-07-3f-3 WELL DESTRUCTION PERMIT <br />