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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 ADDRESS7-o 15- Z CITY/ZIP <br /> { ;y <br /> CROSS STREET `T(Lyh APPARCEL SIZE '(r S LAND USE APPLICATION# <br /> r - T <br /> OWNER J O PHONE 26q <br /> r <br /> OWNER ADDRESS tdt�_ CITY/STATE/ZIP <br /> CONTRACTOR ` "4'5 L&.4QAA S T �_aM+7 PHONE Q.6q 3 Z7- 5/2 0 q <br /> CONTRACTOR ADDRESS 00a . 19 _I 65 CITY/STATE/ZIP L o-et.i G/� !SZ�1 <br /> C-57 WELL DRILLING LICENSE NUMBER EXPIRATION DATE ?6L <br /> PERFORATION CONTRACTOR PHONE <br /> PERFORATION CONTRACTOR ADDRESS CITY/STATE/ZIP <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 JW 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 ❑ Open Bottorn ❑ Gravel Pack ❑ Uncased ❑ Other <br /> Well Log copy attached ❑ Yes ❑ No Grout Seal ❑ No ❑ Yes it below ground surface(bgs) Hole Diameter inches <br /> Well Conductor Casing ❑ Yes ❑ No Depth of Conductor Casing_ it bgs Diameter of Conductor Casing inches <br /> Well Casing Diameter '$ inches Total Depth _")�{ It Depth to Water_._it Depth of Casing it bgs <br /> DESTRUC-ION SPECIFICATION <br /> Sealing Material from it bgs to ft bgs Filler Material 6 from_7� 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 /> ❑ Explosives ❑ Detonating cord ❑ with projectiles every _ ft ❑ without projectile <br /> ❑ Detonating cord and boosters ❑ with projectiles every _ _ ft ❑ without projectile <br /> ❑ Other__ <br /> Sealing Material Neat Cement(94 Ib bag/5-6 gal water) Sand Cement sack mix/7 gal water Se- Bentonite Pellets <br /> oL 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 ft bgs x 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 /> y8 <br /> MINIMUM)4 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br /> CONTRACTORS SIGNATURE TITLE of DATE 7ZV <br /> a <br /> I i <br /> j <br /> DEPARTMENT USE ONLY � 1 <br /> Application Accepted By_ "�—��' Date 7 9 Quad Area "L( <br /> (( <br /> Destruction Inspection By Date �7 Employ ��I <br /> COMMENTS lllr tNte�,ar �� e c'c:SIP. ,St.c,8 �iYs� be [ht'i�'C� + �I�rinair �!� ntJS ��� <br /> 11 <br /> )vt 11f nf ie J�l7 Z�flCiLQ. SroI�yr ' J t� <br /> I zQ2a <br /> 8AN JCA <br /> PE SC Received Check#/ Amount Permit/ NT <br /> Codes Info By Cash Remitted Date Service Request# Invoice, pE gRTM�41el1 ID# <br /> 9373 009,A <br /> IVA <br /> EHD 43-08 � I I O( fi2�2 WELL DESTRUCTION PERMIT <br /> 4/30/12 l (J V <br />