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WELL DESTRUCTION PERMIT <br /> PUBLIC WATER SYSTEM ❑Yes ❑No <br /> SAN JOAOUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1989 East Hazelton Avenue-STOCKTON CA 85205-(209)468.9420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS CrrY/ZIP <br /> CROSS STREAPN PARCEL 9¢E <br /> .^qLAND USE APPLICATION# <br /> OWNER PHONE ti0q. ZQ�'1rJr�41 <br /> OWNER ADDRESS X CITY/STATEMP rT�1�r1^ q1 <br /> CONTRACTOR Y 1 GPHONE-yJZZ'�r11.� <br /> CONTRACTOR ADDR 0 Pig CnYISTATEMPM AlAyQ nI.19;51177DRILLING7 WELL DRILLING LICENSE NUMBER L EXPIRATION DATE DA'711. W . <br /> PERFORATION CONTRACTOR PHONE <br /> PERFORATION CONTRACTOR ADDRESS Cf1Y/STATEMP <br /> ❑ G-57 Well Drilling License Number Expiration Date <br /> ❑ Bureau of Alcohol,Tobacco and Firearms-Users of High Explosives Ucenss 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 Dale <br /> REASON FOR DESTRUCTION Dry ❑ Replacement Well ❑ Caved In ❑ Pit Well ❑ Inactive ❑ Test Hale <br /> Detected/Suspected Well Water Conteminent(s) <br /> Adjacent I§ropertywith contamination(Address) <br /> Known SoiWYator contaminants at adjacent property <br /> Exisnmg WEU CONSTRUCMN DET/UL ❑ Open Bottom X Gravel Pack ❑ Uncased ❑ Other <br /> Well Log Copy altached ❑ Yee x No Grout Seal ❑ No ❑ Yes_it below ground surface(bgs) Hole Diameter Inches <br /> Well Conductor Casing❑ des 'jQ No Depth of Condu 1 Casing t Diameter of Conductor Casing Inches <br /> Wall Casing Diameterr_Inches Total Depth It Depth to Water_tt Depth of Caning It bgs <br /> DESTRUCTION SPECIFICATION t 1 <br /> Sealing Material from W_ft bgs to b _ft bgs Filler Material from it 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 ft and/or <br /> ❑ Explosives❑ Detonating cord ❑ With projectiles every It ❑ wfthout projectile <br /> ❑ Detonating cord and boosters ❑ with projectiles every it ❑ without projectile <br /> ❑ Other <br /> Ssling Material,n Neat Cement(94 Ib beg/5-B gal water)�1 Sand Cement sack mix//gal water n Bentonfte Pellets <br /> 3Bentonite(20%solids) U Manufacturer Spec%solids_% Name ❑ Specs on File ❑ Specs Submitted <br /> Placement Meth Pumped n Free Fall I n Other <br /> Seal Completion Complete with Mushroom Cap=-ft bgs Complete to Existing Surface Pad <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 /> U O R ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br /> CONTRACTORS SIGNATURE TITLE &A*AATE a 1� <br /> E EIV T <br /> i - VED <br /> 010 <br /> -- - -- — — --- — — —_ — Al <br /> JUA <br /> VP1N ��NTY <br /> MENTI <br /> I <br /> I <br /> / DEPARTMENT USE ONLY rJ <br /> Application Accepted By f7�`— Z- L— Date Z/9' ' ' a Area 1 rfr) <br /> Destruction Inspection By Date Employee IDN Sk <br /> COMMENTS <br /> PE SC Received Check#/ Amount Permit/ <br /> Codes Info By_ Cash Remitted Det Service Request# Invoice# Well ID# <br /> 36 ©h0 # - &I <br /> END 43-0e WELL DESTRUCTION PERMIT <br />