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WELL DESTRUCTION PERMIT PUBLIC WATER SYSTEM ❑Yes SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE 3"n FL-STOCKTON CA 95202 - (209)468-3420 NON-REFUNDABLE PERMIT CALL(209)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS J, p � CITY/ZIP oy CROSS STREET ��rrJ O ////��/oma PN la a o3 0o g PARCEL SIZE LAND USE APPLICATION# 0 OWNER ` +/ PHONEy�` OWNER ADDRESS �7/Z �: 5/9L. CITY/STATE/ZIP CONTRACTOR 77 PHONE A/ r^ CONTRACTOR ADDRESS14� L�` CITY/STATE/ZIP I� C-57 WELL DRILLING LICENSE NUMBER EXPIRATION DATE 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 ❑ 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 Depth-7&1/--ft Depth to Water I'/ Depth of Casing ft bgs DESTRUCTION SPECIFICATION Sealing Material from )tlaOi ft bgs to "1y ✓T 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 hag/5-6 gal water) V Sand Cement .suck mix/7 gal water ❑ Bentonite Pellets ❑ Bentonite(20%solids) ❑ Manufacturer Spec%solids % Name ❑ Specs on File ❑ Specs Submitted Placement Method ❑ Pumped ❑ Free Fall W Other� +E ��.-- M Seal Completion ❑ Complete with Mushroom Cap ft bgs ❑ Complete to Existing Surface Pad 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. M 4 DVANCE NOTICE REQUIRED/FOR INSPECTIONS CONTRACTORS SIGNATURE TITLE /J�!/L�� DATE MUM' I - 01 LiltQ i i + s DEPARTMENT USE ONLY Application Accepted By . �' Date 6 a d coal C) Area a /q Destruction Inspection By [C tl2�l`it ktn Date ^41,1716 /1r 716Z� Employee ID#_p T ivy COMMENTS h I fef1Dr dd••'C �"t'C ft S1� Shue t i t fK h) 1 e �5 s� �1 t ,t N^It(�t /n>tetFP/P IJl��1 etttG�IVt'_ SP[d,�►!%r r3(Ot:t'L�L/rPS. LLrQ7L `C�l� lU PE SC Received heck#/ Amount Date Permit/11 I„v.o111 N RONML6 Q Codes Info B Remitted Service Re ues eZlr L13'73 /6 AEL W02, ��Cfr WNT EHD 43-02.008 Well Destruction Permit 1/27/2005