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l L • <br /> WELL DESTRUCTION PERMIT <br /> PUBLIC WATER SYSTEM ❑Yes ❑No <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 East Hazelton Avenue-STOCKTON CA 95205-(209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS NMWD CITY/ZIP n <br /> CROSS STREET. APN - <br /> PARCEL SIZE �L(A�ND USE APPLICATION k C <br /> OWNER �( PHONE O /rtJ 54- <br /> OWNER ADDRESS !� CR7/STATEZP r 17pN G� qg� <br /> CONTRACTOR Y I G• PHONE -VJZZ•1011A <br /> CONTRACTOR ADDRESS I CITY/STATEMPt A�� n�^ <br /> /e C-57 WELL DRILLING LICENSE NUMBER V yy EXPIRATION DATE O_i•�I• fr l- <br /> PERF`ORATION CONTRACTOR PHONE <br /> PERFORATION CONTRACTOR ADDRESS CmY/STATEZP <br /> ❑ C-57 Well Drilling License Number Expiration Date <br /> ❑ Bureau of Alcohol,Tobacco and Firearms-Users of High Explosives License 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-Boaster License Number Expiration Date <br /> REASON FOR DESTRUCMN Dry ❑ Replacement Well ❑ Caved In ❑ Pit Well ❑ Inactive ❑ Test Hole <br /> Detected/Suspected Well Water Contaminant(s) <br /> Adjacent property with contamination(Address) <br /> Known SoiVWater contaminants at adjacent property <br /> EXISTING WELL CONSTRUCTION DETAILS ❑ Open Bottom X Gravel Pack ❑ Uncesed ❑ Other_ <br /> Well Log copy attached ❑ Yes )k No Grout Seal ❑ No ❑ Yes It below ground surface @gs) Hole Diameter inches <br /> Well Conductor Casing❑ Yes )q No Depth of Condu to Casing h I Diameter of Conductor Casing _inches <br /> Well Casing Diameter__inches Total Depth R Depth to Water,-it Depth of Casing _it bgs <br /> DESTRUCTION SPECIFICATION I <br /> h1 <br /> Seating Material from h bgs to V _ it bgs Filler Material_ from __ ft bgs to_ ft bgs <br /> Well casing to be perforated by one of the following methods - from If bgs to _ it bgs <br /> ❑ Mills Knife Number of cuts every it and/or <br /> ❑ Explosives❑ Detonating cord ❑ with projectiles every it ❑ without projectile <br /> ❑ Other Detonating cord and boosters ❑ with projectiles every it ❑ without projectile <br /> S11 9 Material ' Neat Cement(94 Ib bagi5.6 gal water) Sand Cement sack mix/7 gal water n Bentonite Pellets <br /> Bentonite(20%solids) Manufacturer Spec%solids_% Name _ Specs on File ] Specs Submitted <br /> Placement M.thV X Pumped 'i Free FallOther <br /> Seal Completion Complete with Mushroom Cap It bgs Complete to Existing Surface Ped <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 /> INNIALI OUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br /> CONTRACTORS SIGNATURE TITLE WN ATE O 1�• <br /> Y EN <br /> - T <br /> - - - - - CiEQED <br /> 010 <br /> � UIN <br /> IZPA <br /> Ir 7N <br /> - -- V R N-C Erv�E COUNTYT <br /> PQR MENT <br /> i <br /> l DEPARTMENT USE ONLY <br /> Application Accepted By ' Date i l 4 A. <br /> Destruction Inspection By Date 1-0 Emp"10# .A <br /> COMMENTS <br /> PE Sc Regebved Check#/ Amount Da Permltl Invoice# Well ID# <br /> Codes htfo 8 Cash Remitted Service Request• <br /> 0 q Dpi <br /> EHD 43-08 WELL DESTRUCTION PERMIT <br />