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WELL DESTRUCTION PERMIT <br /> PUBLIC WATER SYSTEM ❑Y7 <br /> 9) NO <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE 3""FL-STOCKTON CA 95202 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL(209)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS CITY/ZIP <br /> CROSS STREET A APN J / O PARCEL SIZE LAND USE APPLICATION <br /> `#� tv <br /> OWNER PHONE '�!/ /O ! / v <br /> �- rn <br /> OWNER ADDRESS CITY/STATE/ZIP —1 <br /> CONTRACTOR //" 117—V2 PHONE !7: :3;Vz <br /> CONTRACTOR ADDRESS LC�� CITY/STATE/ZIP <br /> C-57 WELL DRILLING LICENSE NUMBER EXPIRATION DATE <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 I)et <br /> ❑ CHP Hazardous Material Transportation for Explosives License Number Expiratio a ee <br /> ❑ San Joaquin County Sheriff-Coroner Explosives Application and Permit License Number Expiratiofte <br /> ❑ California Occupational Safety Health-Blaster License Number Expiratio ate <br /> REASON FOR DESTRUCTION ❑ Dry Replacement Well ❑ Caved In ❑ Pit Well ❑ Inactive T t A02020 <br /> Detected/Suspected Well Water Contaminn� t(s) <br /> Adjacent property with contamination (Address) H NVI ONQ¢F. � <br /> Known Soil/Water contaminants at adjacent property �4t7 �EpARTAfEftri— <br /> EXISTING WELL CONSTRUCTION DETAILS ❑ Open Bottom ❑ Gravel Pack ❑ Uncased ❑ Other <br /> Well Log copy attached ❑ Yes ❑ No Grout Seal ❑ No ❑ Yes ft below ground surface(bgs) Hole Diameter inches <br /> Well Conductor Casing ❑ Yes ❑ No Depth of Conductor Casing ft gf� Diameter of Conductor Casing in he <br /> Well Casing Diameter� h inches Total Depth ft Depth to Water '%99 ti Depth oCasing bgs <br /> DESTRUCTION SPECIFICATION <br /> Sealing Material from 17k ft bgs to ft bgs 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 /> ❑ 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 lb hug/5-6 gal wafer) ❑ Sand Cement suck mix/7 gal water Bentonite Pellets <br /> ❑ Bentonite(20%solids) ❑ Manufacturer Spec%solids % Name ❑ Specs on File ❑ Specs Submitted <br /> Placement Method ❑ Pumped,IV Free Fall ❑ Other <br /> Seal Completion ;V Complete with Mushroom Cap tl bgs ❑ Complete to Existing Surface Pad <br /> 1 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. 1 ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT 1 AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> 24 ADVANCE NOTICE REQUIRED FOR'INSPECTIONS <br /> CONTRACTORS SIGNATURE TITLE �iL%/L� DATE e�U�z� <br /> MAX I <br /> C <br /> LLa 1 1 1 <br /> i - — <br /> DEPARTMENT USE O N L <br /> Application Accepted By -_�"' Date JI Area <br /> Destruction Inspection By I Date Employee ID# DR <br /> COMMENTS <br /> PE SC Received Ch Amount Date Permit/ Invoice# Well ID# <br /> Codes Info I Cash Remitted I Servi_ a R%guest# <br /> eke D 4 4 1<__2 III , LH <br /> EHD 43-02-008 Well Destruction Permit <br /> 1/27/2005 <br />