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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 PERMITCALLCALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS �- f CfTYRIP CROSS STREET APN — PARCEL SIZE LANG USE APP KATION e n OWNER D/ PHONE OWNER ADDRESSlc� utwurmil V CrTY/STATE/ZIP -} u CONTRACTORMIN PHONE Z' Zi, CONNTJRACTOR ADDRESS C./STATE/ZIP J l� C-57 WELL DRILLING LICENSE NUMBER to 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 Explration 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 Cl Caved In ❑ Pit Well ❑ Inactive ❑ Test Hole Detected/Suspected Well Will onteminent(s) Adjacent property with contamination(Address) Known Soil/Waler contaminants at adjacent property ExisT1NG WELL CONSTRUCTION DETAILS ❑ Open Bottom ❑ Gravel Pack ❑ Unrased ❑ Other Well Log copy attached 13Yea No Grout Sul y( No ❑ Yes it below ground surface(bgs) Hole Diameter inches Well Conductor Casing❑ Yes No Depth of Conductor Casing ft s Diameter of Conductor Casing inches Well Casing Diameter u_inches Total Depth -._._it Depth to Water_t__,.It Depth of Casing It bgs DESTRUCTION PE IFP AT N }� Sealing Material fro YU it bgs to�_ft bgs Filler Material _from it bgs to ft bgs Well casing to be perforated by one of the IOIIOWinc methods:__- from ____ft 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 R ❑ without projectile ❑ Other WJU Xav" Material ' Neat Cement(94 lb begi5-6 gal wafer) Sand Cement _ sack mix/7 gal water - Bentonite Pellets entonite(209:soy ds) _I Manufacturer Spec 9',solids % Name _ Specs on File Specs Submitted Bent Method ?\ Pumped i Free Fall I O er Seal Completion'l�Complete with Mushroom Cap � 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. Im MI IM O ADVANCE NOTICE REQUIRE 41' O IN PECTIONS CONTRACTORS SIGNATURE TIT \ DATE ..... 41— 1 1 14 F NT 4 - - c A ^lO Ty la ek DEPARTMENT USE ON Y Application Accepted By Date a3 aoaa Area n Destruction Inspection By-111460"kefc Date Employee IDM ;/ COMMENTS PE Sc Received Checks/ Amount Date Permit/ Invoice 0 Well IDs Codes Info B Cash Remitted Service Request s y3C4' OFO EHD 13-08WELL DESTRUCTION PERMIT / Oa !