WP0040895 - 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-(2D9)468-3420 NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS CrTY21P D CROSS ST EFT MON M. APN CPARCELSVE4 LANDUSEAP1PnLICATION N Yy HONE OWNER Pr OWNER ADDRESS Cr1Y/STA^TE/^Z1AP CONTRACTOR PHONE �`� CONTRACTOR ADDRESS CITY/STATEIZIP 1 VII/ N• ��3�1 y� C-57 WELL DRILLING LICENSE NUMBER EXPIRATION DATE lam,?JO-Mill PERFORATION CONTRACTOR PHONE PERFORATION CONTRACTOR ADDRESS CrFYISTATEIZIP ❑ C 57 Well Drilling License Number Expiration Date ❑ Bureau of Alcohol.Tobacco and Firearms-Users of High Explosives License Number Expiration Dale ❑ 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 FOA 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 properly ExisTING WELL CONSTRUCTION DETAI✓LS ❑ Open Bottom ❑ Gravel Pack ❑ Uncased ❑ Other _ Well Log copy attached ❑ Yes No Grout So.[>( No ❑ Yes It below ground surface(bgs) Hole Diameter-_. Inches Well Conductor Casing VeS X No Depth of Co-A—-Casing _ it ti. Diameter of Conductor Casing _. .__ _inches Well Casing Diameter inches Total Depth �O h Depth to Water— 47 _ ft Depth of Casing-___-._It bgs DESTRUCTION SPECIFICATION 1F'L' F�' I Sealing Material from f'_`TI�Nt ft bgs to �-' It bgs Filler Material_— _ -____..._ from it bgs to _It bgs Well casing to be perforated by one of the following methods: from It bgs to___it bgs ❑ Mills Knife Number of cuts every ft and/or ❑ Explosives❑ Detonating cord ❑ with projectiles every-___ it ❑ without projectile ❑ Detonating cord and boosters ❑ with projectiles every _-ft ❑ without projectile ❑ Othe_ — --- -- -- S�eals'I Material Neat Cement(94 Ib bag/5-6 gal water) Sand Cement _sack rrllx7 gal water 3entonite Pellets X`Bentonite(20%solids) Manufacturer Spec 0-6 solids o Name _I Specs on File • Specs Submitted lac merit Method Pumped Free Fal I CAW Seal Completion Complete with Mushroom Cap____ _.---- It bgs Complete to Existing Surface Pad 1 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. yg M17114 It HRUJ ADVANCE NOTICE REQUIRED FOR CONTRACTORS SIGNATURE TITLE%W1'v, •'DATEIWV— t/0 1 •'W YO I - - -- I J-1- 18 ENV RO U'N;Cd U -rut T Y - 21 - - - - - VT DEPARTMENT USE ON Y Application Accepted By _ Date �' 7 i d Oa 0 Area I Destruction Inspection By Date Employee DN 5K COMMENTS I e- IL4}E/!O! Ie f L/tShC511 0',51 ed 40 e anji Oil ' ims ll h I101 '/l h er rP i'MI, is 1(ee 11M Hr 4/ per P Qr '� PE SC Received ChedW Amount Permit/ r w _ Info ash Remitted Date S -ce Request A Invoice N Well IDN 01 0 S LHO 43.08 / /D p- WELL DESTRUCTION PERMIT 4110.12