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WELL DESTRUCTION PERMIT PUBLIC WATER SYSTEM ❑Yes ❑No SAN JOAOUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 East Hazelton Avenue-STOCKTON CA 95205 - (209)468-3420 NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED JOB ^ ADDRESS t1YJe� �«i�LtY►1Ptn�O CITY/ZIP LJ6-i CROSS STREET APN o5 D 30 30 PARCEL SIZE=' f LAND USE APPLICATION# C OWNER 7'.." ve'— PHONE ) r OWNER ADDRESS CITY/STATE/ZIP CONTRACTOR K_Y",Tlt- (1-.1w jtl5 PHONE CONTRACTOR ADDRESS w• O • �x CITY/STATE/ZIP C-57 WELL DRILLING LICENSE NUMBER �6��fZ 3 EXPIRATION DATE 7-6 7-1 PERFORATION CONTRACTOR PHONE PERFORATION CONTRACTOR ADDRESS 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 A Dry ❑ Replacement Well ❑ Caved In ❑ Pit Well ❑ Inactive ❑ Test Hole Detected/Suspected Well Water Contaminant(s) Adjacent property with contamination(Address) Known Soil/Water contaminants at adjacent property EXISTING WELL CONSTRUCTION DETAILS ❑ Open Bottom ❑ Gravel Pack ❑ Uncased ❑ Other Well Log copy attached ❑ Yes ❑ No Grout Seal ❑ No ❑ Yes It below ground surface(bgs) Hole Diameter inches Well Conductor Casing ❑ Yes ❑ No Depth of Conductor Casing ft bgs Diameter of Conductor Casing inches Well Casing Diameter J 0 _ _ inches Total Depth 3S It Depth to Water__-57-2- It Depth of Casing _ _it bgs DESTRUCTION SPECIFICATION Sealing Material from 3 _ it bgs to - 3 Ss ft bgs Filler Material_ _from 3 ft bgs to '34 .ft bgs Well casing to be perforated by one of the following methods: — _from _ ft bgs to It bgs ❑ Mills Knife ________........._..._......-Number of cuts every______ft and/or ❑ Explosives ❑ Detonating cord ❑ with projectiles every ft ❑ without projectile ❑ Detonating cord and boosters ❑ with projectiles every ft ❑ without projectile ❑ Other Sealing Material Neat Cement(94 ib bag/5-6 gal water) I Sand Cement /A.'3 sack mix17 gal water Bentonite Pellets Bentonite(20%solids) Manufacturer Spec%solids _% Name Specs on File Specs Submitted Placement Method Y Pumped 1 Free Fall 11 Other Seal Completion Complete with Mushroom Cap _3 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 I AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION LAWS. Yb MIN UM X HOUR ADVANCE NOTICE REQUIRED FOR_INSJP'_E,CTIONS CONTRACTORS SIGNATURE TITLE [�� DATE ZO i _ PAYE ,1 0 _...._..._._..._.._.J.._._.. -- - ......__............__ ... ._.......... _... _ .. ... .. H �vl Qu//V EALTy AFP EIV t r I ART Me _... ._ _._ ........ __ _.._.. _..._ _.—....._......._...__......_..............___. — _. _._._..._...................__-_..---- --—_.__._.._..._ I 14 DEPARTMENT USE ONLY Application Accepted By �` Date g a0� Area L�e/j Destruction Inspection By Date �{��"� Employee ID# DA COMMENTS r .cS61: '�. In 64j2nd ;,)n o-rd vir / ^,av 40SC 1'� I�Xf fofe24rIfnro e -t-o be PE SC Received Check#/ Amount Date Permit/ Invoice# Well ID# Codes Info B Cash Remitted Service Request# t Il 7 V EHD 43-08 WELL DESTRUCTION PERMIT 4/30/12