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WELL DESTRUCTION PERMIT may/ • PUBLIC WATER SYSTEM El Yes,L`l No SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPT 1868 East Hazelton Avenue-STOCKTON CA 95205.6232[-(209)468-3420 NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTic EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS z3 O 5 . 1! %Q A t*Ghyf � •-� CITY/LIP Trac)( 1155-1(,p CROSS STREET —� C.(�',Q 1Qn APN 2,5Z-IPSO-Q 1 PARCEL SIZE 7 y(L�A�NtD USE APPLICATION# OWNER E Mgdt 60,5 MMS, PHONE �14 i 1 `�' /� OWNER ADDRESS 23 8Q S• 1 �Q C�r�/� y r y.�CITYISTATEZPmy- CA lc,-374, _ CONTRACTOR • ,{,.t P\ `• d QQ-1J7-MONE s Ll I Sic; CONTRACTOR ADDRESS 1_`f j a ^ p CrTY/STATEZP C 29 1 O C-57 WELL DRILLING LICENSE NUMBER 01; EXPIRATION DATE 'J ;J `• PERFORATION CONTRACTOR PHONE PERFORATION CONTRACTOR ADDRE CITY/STATEZP C-57 Well Drilling License Number Z9C)01 3 Expiration Date rl' ((( 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 ❑ Caved In ❑ Pit Well nactive ❑ Test Hole Detected/Suspected Well Water Contaminant(s) Adjacent property with contamination(Address) Known Soil/Water contaminants at adjacent property__ EXISTING WELL CONSTRUCTION DETAIL 111 Open Bottom ❑ Gravel Pack ❑ Uncased ❑ Other Well Log copy attached ❑ Yes No Grout Seal ❑ No ❑ Yes ft 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('�ft,:dfhes Total DeplhesA-.,_ft Depth to Water ft Depth of Casing ft bgs Dl'_VTR1*CTIONSPE('IFR':\'FIONgohf.,;.,�A•�e bi Sealing Material from Q ft bgs to LJQ ft bgs• Filler Material_ from ft bgs to ft bgs Well casing to be perforated by one of the following methods, from ft bgs to ft 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__ Sealjng Material Neat Cement(94 Ib bag/5-6 gal water) Sand Cement sack mix/7 gal water Bentonite Pellets XBentonite(20% olid ) Manufacturer Spec%solids_% Name Specs on File Specs Submitted Placement Method jZ 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. MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR SP`E'CTIONS ZD CONTRACTORS SIGNATURE , I TI�5 �{��• DATE t i I T— PAIV E� 1 ZpZp SAN /O AQUI DEPARTMENT USE ON ' ��(:TypEpq��AL Application Accepted By Date 7 J r Area MF(VT ##EE Destruction Inspection By_ 11 Date 9 Employee ID# COMMENTS C-)hl'1r�x'1)1 f'a ('j PE Sc Received hec Amount Date Perms Invoice# Well ID# Codes Info B ash Remitted is ReAuest# X373 ►'~ f EHO 43-08 WELL DESTRUCTION PERMIT 1015/07