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WELL DESTRUCTION PERMIT PUBLIC WATER SYSTEM ❑Yes ❑No SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT IBOB East Hazellon Avenue-STOCKTON CA 95205-(209)466-3420 NON-REFUNDABLE PERMIT CALL 208 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED Joe ADDRESS 1\9-7 Crrv/ZIP 0 > CROSS STREET4hO7N111111 APNI11— I'MPARCEL SIZE4 LAND ✓/J�USE APPLICATION i t' YV� O 1`I • V C PHONE OWNER r V OWNER ADDRESS CrTY/STATEIZIP D H CONTRACTOR PHONE 'Imrr CONTRACTOR Ac""'L—H CfTY/STATE/LP nn ^631 4 C-57 WELL DRILLING LICENSE NUMBER rbvvEXPIRATION DATE _ V•(/l/✓' PERFORATION CONTRACTOR PHONE PERFORATION CONTRACTOR ADDRESS CrTY/STATEMP ❑ C-57 Well Drilling License Number Expiration Data ❑ Bureau of Alcohol.Tobacco and Firearms-Users of High Explosives License Number Expiration Dale ❑ CHP Hazardous Malarial Transponatlon for Explosives License Number Expiration Dale ❑ San Joaquin County Sheriff-Coroner Explosives Application and Permit License Number Expiration Dale ❑ California Occupational Safely Health-Blaster License Number Expiration Dale REASON FOR DESTRUCTION XDry ❑ Replacement Well ❑ Caved In ❑ Pit Well ❑ Inactive ❑ Test Hole 0alected)Suspacted Wall WaTer Conleminanl(s) Adjacent propertywith contaminallon(Address) Known Soil/Waler contaminants at adjacent properly EXISTING WELL CONSTRUCTION DETAtl3 ❑ Open Bottom ❑ Gravel Peck ❑ Uncased ❑ Other Well Log copy attached ❑ Yes �No Grout Seal>(No ❑ Yes it below ground surface(logs) Hole Diameter Inches Well Conductor Casing os No Depth of Co",--,--Casing it Diameter of Conductor Casing Inches Well Casing Diameter_ Inches Total Depth II Depth to Water— It Depth of Casing It logs OE i 771F Seeling Melarlel from -'r�'�It bgs to 0 ft bps Filler Materiel from ft bgs to it bgs Well casing to be perforated by gns of the following methods: from It bgs to It bgs ❑ Mills Knife Number of cuts every it and/or ❑ Explosives❑ Detonating cord ❑ with projectiles every It ❑ without projectile ❑ Detonating cord and boosters ❑ with projectiles every Il ❑ without projectile ❑ Other S e 11Mtil r- Neat Cement(94 fb bag/5-6 gal water)-' Sand Cement sack m/x/7 gel water 3enlonite Pellets (20Y solids) :J Manuleclurer Spec%solids % NemeI It Two L Specsonnfe •.J SpecsSubmitted enl Method Pumped � Free Fa r 1 66!r Seal CGmpiallon Complete with Mushroom Cep'It 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. Yp MINI / H U ADVANCE NOTICE REQUIRED F`R'(I�N ECTIONS CONTRACTORS SIGNATURE ♦ TITLE w t 1 DATE V0 1 •'�'1�0 F7 4 _ , - -C � VA- N /" U — -- - - - - - - - - - _. . — - - - - —— Ty _ _-rtzT DEPARTMENT USE 07Y Application Accepted By t /"�"��Z_ Gala Area Destruction Inspection By Dale Employee r; COMMENTS 'I )) )e. 'ar;Or 9Sfile <Ct lr dwil Cftzsl eG, U 40111111n)le 6flf Ube" 1J1)S O,. Ij 111 C I m) 'bt ;n ftzrfere •i MIT -�c, a SEt,hl7- IL,i": IPS. HW, . /eta' tdoill toot, SFY'( yt i 1N -r - s •I , t?e It Er >evr 'f PE SC Received Checks/ Amount Perm)U Info ash Remitted Dete S rvlce Request i Invoice i Well IDs 34.43 EHD 08 / /D p- y WELL DESTRUCTION PERMIT 4130112 4 G/ L/�_ D (/