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•' WELL DESTRUCTION PERMIT <br /> PUBLIC WATER SYSTEM ❑Yes ❑No <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPT 1868 East Hazelton Avenue-STOCKTON CA 95205-6232-(209)468-3420 <br /> NON-REFUNDABLE PERMIT -ALL(209)S53-7597 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> a <br /> JOB ADDRESS SSS/ E osh a w K CITv2Stockton, CA <br /> 1P <br /> CROSS STREET Ii /a!x APN /73S-10/7 PARCEL SIZE_LAND USE APPLICATION# tv <br /> OWNER Ernie Vastl PHONE 209-610-1524 <br /> OWNERADDRESS PO BOX 4057 CrrY/STATEIZJPStocktan_- CA 95204 <br /> CONTRACTOR Purviance Drilles, Inc PHONE 209-887-3554 <br /> CONTRACTOR ADDRESSPO BOX 64 CITY/STATE/ZJP Lindenr CA 95236 <br /> C-67 WELL DRILLING LICENSE NUMBER 377923 EXPIRATION DATE 3 1 2 1 <br /> PERFORATION CONTRACTOR n/a PHONE <br /> PERFORATION CONTRACTOR ADDRESS CrTY/STATE/7iP <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-Blaster License Number Expiration Date <br /> REASON FOR DESTRUCTION ❑ 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 Soil/Water contaminants at adjacent property <br /> EXISTING WELL CONSTRUCTION DETAILS X Open Bottom ❑ Gravel Pack ❑ Uncased ❑ Other <br /> Well Log copy attached ❑ Yes ,� No Grout Seal )4 No ❑ Yes ft below ground surface(bgs) Hole Diameter inches <br /> Well Conductor Casing❑ Yes No Depth of Conductor Casing ft bgs Diameter of Conductor Casing inches <br /> Well Casing Diameter ,1/0N9 inches Total Depth ft Depth to Water ft Depth of Casing Ab vg ft bgs <br /> DESTRUCTION SPECIFICATION <br /> Sealing Material from 0 ft bgs to 3/6dAl Filler Material from ft bgs to ft bgs <br /> Well casing to be perforated by one of the following methods: from ft bgs to ft bgs <br /> ❑ Mills Knife Number of cuts every ft and/or <br /> Cl Explosives❑ Detonating cord ❑ with projectiles every it ❑ without projectile <br /> ❑ Detonating cord and boosters ❑ with projectiles every it ❑ without projectile <br /> ❑ Other <br /> Sealing Material Neat Cement(941b bag/5-6 gat water) Sand Cement /D.3 sack mix 17 gat water Bentonite Pellets <br /> Bentonite(20%solids) Manufacturer Spec%solids_% Name Specs on File Specs Submitted <br /> Placement Method Pumped Free Fall. Other <br /> Seal Completion Complete with Mushroom Cap 3 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 /> Ivl� 'MUM R ADVANCE NOTICE REQUIRED FOR iNSPs_CT'C;S r '\ <br /> •1 CONTRACTORS SIGNATURE_ �-�� TITLE DATE—16'`�-�d� <br /> I <br /> MAY <br /> 04 1010 <br /> - - - +- SAN <br /> E"JV <br /> } s i <br /> DEMH Tq�TY HEATH <br /> TMENT <br /> I - <br /> s�7 DEPARTMENT USE ONLY <br /> Application Accepted Z-1— 9 <br /> Area <br /> Destruction Inspection By �` Date Employee IDIf <br /> COMMENTS� 14 f'1?rlor �' 1'fIQ <br /> f n1 1 <br /> stv[ <br /> it n rfere h ,Fv <br /> I Z c%G o OPS <br /> Z/�� vl ^. u C h A�%s� -sPl3� Ll i <br /> � IL? All . <br /> PE Sc Received Check#! Amount Date PermiU Invoice# WeIIIDa <br /> Codes Info Cash Remitted S rvice Request# <br /> EHD 43 r^ WELL DESTRUCTION PERMIT <br /> revised 4/111 4/'18 /l�Tr /7,?i/9A <br />