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t � WELL DESTRUCTION PERMIT PUBLIC WATERSysum ❑Yes ❑No SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPT 1868 East Hazelton Avenue-STOCKTON CA 95205-6232-(209)4683420 NON-REFUNDA6LE PERMIT (:AWOS)953-7697 Foy til$?Li. EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS ew as a CITYZP Stockton, CA CROs STREET /C APN /8 I J/005 PARCEL SIZE 7 LAND USE APPLICATION# o OWNER Pete Thompson n PHONE 209-482-1 872 OWNERADDREss 8 9 Q 3 E Lath,r Qp R d CrTYISTATE/ZIP CONTRACTOR Purviance Drillers, Inc PHONE 20779''-887-35 4 CONTRACTOR ADDRESS PO BOX CrfY1sTATE/LNinden, CA 95236 C-5T WELL DRILLING LICENSE NUMBER 377923 EXPIRATION DAT7/31 /21 ,L PERFORATION CONTRACTOR'r Well l Water We f 4itd61 PHONE 9�G�7-��P��5V1/-I PERFORATION CONTRACTOR ADDRESS P0156Y ��FS CrTYISTATE/ZIP �Tr�� C-57 Wen Drilling /� `� License Number Expiration Date Bureau of Alcohol,Tobacco endeR(arms-Users of High Explosives License Number Expiration 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 0 apational Safety Health-Blaster License Number Expiration Date REASON FOR DESTRUCTION ❑ Dry ❑ Replacement Well ❑ Caved In ❑ Pit Well 10 Inactive ❑ Test Hole Detected/Suspected Well Water Contaminant(s)_,fj!Lf A. Adjacent property with contamination(Address)_ Known Son 1 Water Contaminants at adjacent property i ie"s— EXISTING WELL CONSTRUCTION DETAILS 10 Open Bottom ❑ Gravel Pack ❑ Uncased ❑ Other Well Log copy attached ❑ Yes I No Grout Seal ❑ No ❑ Yes____ It below ground surface(bgs) Hole Diameter Irlchee j Well Conductor Casing 13 Yes It No Depth of Conductor Casing All* It bgs Diameter of Conductor Casing InMles Well Casing Diameter ICA inch. Total Depth Li�It Depth to Water&'�_ft Depth of Casing If bgs DESTRUCTION SPECIFICATION Sealing Material from 100 ft bgs to ft bgs Filler Material Cevrr?J- _from X00 It bgs to_ 0 It bgs Well casing to be perforated by one of the following methods: from ft bgs to ft bgs ❑ Mills Knife Numberofeutsevery_ _ ft and Explosives Cl Detonating cord ❑ with projectiles every ft ❑ without projectile Z Detonating cord and boosters ❑ with projectiles everyft 14'without projectile ❑ Other _ \ Sealing Material Neat Cement(g4 ib bag/56 gat water 91S Sand Cement(Q sack mix/7 gal water(1 g51� Bentonite Pellets Bentonite(20'X solids) Manufacturer pec%solitls % Name Specs on Fie Specs Submitted Placement MethodPu ped Free Fall Other d�� Seal Completion Complete In Mushroom Cap ft 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 LICENS IS Y C CURRENT AND ACTIVE WITH THE CAUFORNIA CONTRACTORS STATE UCENSE BOARD AND THAT I AM IN COMPLIANCE WITHA�� WORKERS COMPENSATION LAWS. F' A1"-k1!11,.'-'3"-!10T:C= c i..= =C.^,'.;zc�. JpgQ(l CONTRACTORS SIGNATU .`' TITLE DATE �kON�gEtv001I n' 4 L R N&NT r � /) DEPARTMENT USE ON Y Application Accepted By C/ —I- `' Date L 0^0 Area / r Destruction Inspection Bppy Date '1 Employee IDe CO�i N)�T.,S��( r i0f../(':111 ;o ', r L(/ , 0 C f ooTC Amo � �/ PE SC Received Chack#1 Amou t Permit/Codes Info Cash Remitted Dau ServiceR uest# Invoice# We{IID# f�qy 10043-09 /' Yew/_� /D7��j1V✓EI.LDESTRUCTION PERMIT tasro7 /-J^1fLl/�"11�` ` / `JL/