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i t WELL DESTRUCTION PERMITe— PUBLIC WATER SYSTEM ❑Yes SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPT 1868 East Hazelton Avenue-STOCKTON CA 95205-62322 (2``09)468.3420 NON-REFUNDAB(L�E PERMIT _C`Ar.LL(209)953-7697 FOR INSPECTIONS �T'EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS 1 -\ A I ry ` CITYZP S `O Q CROSS STREET • \-1)pl L 1) C APN 1 I / -4�v j ` PARCEL SIZE_fS_j�LAND USE APPLICATION OWNER KRS �J Me 0� 6a Mn O I PHONE a- 60 OWNER ADDRESS -1 a Irv5 N I r I`-'� CITY/STATE/ZIP T CIL'•4 C CONTRACTOR PHONEO� CONTRACTOR ADDRESS ,D� I ('O CITY/STATE21P �''v" �-��C-1` lam_, `i S I_ e C-57 WELL DRILLING LICENSE NUMBER EXPIRATION DATE Or- PERFORATION CONTRACTOR N I PHONE PERFORATION CONTRACTOR ADDRESS 1,1 1 A CITY/STATE/ZIP C-57 Well Drilling License Number Expiration Date Bureau of Alcohol,Tobacco and Firearms-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 Occupational Safety Health-Blaster License Number Expiration Date REASON FOR DESTRUCTION ❑ Dry ❑ Replacement Well -a Caved In ❑ Pit Well -49 Inactive ❑ Test Hole Detected/Suspected Well Water Contaminant(s) 0 !�1 Adjacent property with contamination(Address) Known Soil I Water contaminants at adjacent property EXISTING WELL CONSTRUCTION DETAILS ❑ Open Bottom ❑ Gravel PaCk ❑ UnraSed ❑ Other Well Log copy attacheC ❑ Yes ❑ No Grout Seal ❑ >o ❑ Yes h below ground surface(Ns) Hole Diameter inches Weil Conductor Casing❑ Yes ❑ No Depth of Conductor Casing ft bgs Diameter of Conductor Casing inches Well Casing Diameter `O inches Total DepthI 3 it Depth to Water h Depth of Casing h bgs DF I TRI CTin\SPL(TF IC%Itn\ Sealing Material from 8 It bgs to IC h bgs Filler Mated, from ft bps to_ft bpi Well casing to be�rfTted by one of the following methods: u A rrom ft bpi to It bps ❑ Mills Knife Number of cuts every h and/or ❑ Explosives❑ Detonating cord ❑ with projectiles every R O without projectile ❑ Detonating cord and boosters ❑ with projectiles every It O without projectile ❑ other W k- , Sealing Material Neat Cement(94 Ib bag/5-6 gal water) Sand Cement sack mix 17 gal water Bentonite Pellets Bentonite(20%solids) nufacturer Spec%solids 31-0% Name Specs on File Specs Sub—led Placement Method Pumped Free Fall Other Seal Completion Complete wi ushroom Cap LA h 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 LICENSE IS CURRENT AND ACTIVE WITH THE CALIFORNIA CO CTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION LAW . M OVANC NOTICE REQUIRED FOR INSPECTIONS t CONTRACTORS SIGNATURE TITLE 1f9A' Or-DATE q�yMENT AFD S e -e ��. �� SAN .l 30 2020 EN QU/ HFq�TyFP eN0L/ NT1' ARTMENT 1 DEPARTMENT USE ^"I V Appliaton Atxeptetl By /` 1 Area d TO L Date 7 y�0' L� o ri Destivctlain Inspection By Date s Employee ID# COMMENTS r: Jf F n all f`r i a Jew Ill ctlons fn Wkr e r e I r Il i �tly 11 z< pE SC RsCslVad Amount Date Permit/ Invoice# Well ID# Codas Irft B casn Remitted ice R uest# 4373 I6 -->�l ILS EHE)4308 • � /// f� WELL DESTRUCTION PERMIT revised 4114/18 � Q / /