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WELL DESTRUCTION PERMIT PUBLIC WATER SYSTEM ❑Yes ❑No SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE 3""FL-STOCKTON CA 95202 - (209)468-3420 NON-REFUNDABLE PERMIT - CA L(209)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED 5aaJOB ADDRESS CITY/ZIP 1 Q / � CROSS STREET APN ��I O`�O PARCEL SIZE I t ` LAND USE APPLICATION# o < A PHONE OWNER gog i OWNER ADDRESS / CITY/STATE/ZIP y � �%h- t CONTRACTOR I/Ar�A7Jx'?(�'/,,-,<cti •� 't //r't�( i��/' PHONE �� / ' S�j� - � / b CONTRACTOR ADDRESS t 1q n�Q�/1PAt' ice" CITY/STATE/ZIP 1A ppjvl� CIL) C-57 WELL DRILLING LICENSE NUMBER i4(9F t'' EXPIRATION DATE PERFORATION CONTRACTOR PHONE PERFORATION CONTRACTOR ADDRESS --- CITY/STATE/ZIP (41 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 1� Replacement Well ❑ Caved In ❑ Pit Well ❑ Inactive ❑ Test Hole Detected/Suspected Well Water Contaminant(s) N"0 -e Adjacent property with contamination (Address) P""N4 Known Soil/Water contaminants at adjacent property W Ce'I EXISTING WELL CONSTRUCTION DETAILS 'F,Open Bottom ? ❑ Gravel Pack ❑ Uncased ❑ Other Well Log copy attached ❑ Yes O No Grout Seal ❑ No ❑ Yes tt below ground surface(bgs) Hole Diameter inches Well Conductor Casing ❑ Yes ❑ No Depth of Conductor Casing tt bgs Diameter of Conductor Casing �� inches Well Casing Diameter�—winches Total Depth /q(3 ft Depth to Water ft Depth of Casing tt bgs DESTRUCTION SPECIFICATION Sealing Material from _ft bgs to 7ur ft bgs Filler Material AJ t from ft bgs to ft bgs Well casing to be perforated by one of the following methods: from tt bgs to ft bgs ❑ Mi nife Number of cuts a tt and/or ❑ Explosiv ❑ Detona cord with pro tiles every ft ❑ ;the> out projectile Detonating c and boosters with project) every ❑ with rojectile ❑ Other Sealing Material ❑ Neat Cement(94/h hug/5-6 gal water) ❑ Sand Cement suck mix/7 gal water ❑ Bentonite Pellets f Bentonite(20%solids) ❑ Manufacturer Spec%solids % Name ❑ Specs on File ❑ Specs Submitted Placement Method P( Pumped ❑ Free Fall ❑ Other Seal Completion ❑ Complete with 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 LICENSE IS CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT 1 AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION LAWS. MIN UM 24 HOUR ADVANCE NOTICE REQUIRED FFO- R INSPECTIONS CONTRACTORS SIGNATURE 1 711,— - TITLE W%7 .(ec DATE l\V Q RF Y°�FNr FD sgN0�UO 2 � 2420 ENV/gQUlly C h�LTy DEP ��T Y FNT f� DEPARTMENT USE O LY r� Application Accepted By �`—� (� Date 11�;pJ1 0A2 Area Destruction Inspection By I GJw�/L Date (J12 3 '7- Employee ID# COMMENTS X-'( 1+c' Ad rl'P( I7J ' r' / V ni?om- ,- ' LX4 well C0411 dt 1109 r-1aL L's i PE SC Received Check#/ Amount Date Permit/ Invoice# Well ID# Codes Info By Remitted a vice Re uest# END 43-02-008 Well Destruction Permit 1/27/2005