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WELL DESTRUCTION PERMIT �f PUBLIC WATER SYSTEM E)Yes 1!(J No SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPT 1868 East Hazelton Avenue-STOCKTON CA 95205-6232-(2(209)468-3420 NON-REFUNDABLE/PERMIT WALL 209 953-7697 FOR INSPECTIC: EXPIRES 1 YEAR FR OM DATE ISSUED JOB ADDRESS V -Ye . rvIZI 1 crP� l n r—[fit o'% 7 ,16 a rk CROSS STREET APN 1'71-S(0O { PARCEL SIZE4 r�LAND USE APPLICATION# �/ OWNER r'0 — V PHONE 41 �]�, O V O.+►O ( Qh`e�.�Q OWNER ADDRESS t� ` 1 I O�—1 zl en C r C,l e CITU/STATE21P ..J[� [ 1 D i C �1 J[J.17 CONTRACTOR PHONE 5 LA 5- 1 10 5 CONTRACTOR ADDRESS�q'� �I d,C,ILDI^ CRY/STATE21P C C-57 WELL DRILLING LICENSE NUMBER EXPIRATION DATE PERFORATION CONTRACTOR PHONE PERFORATION CONTRACTOR ADDRESS Crry/STATE/ZIP t C-57 Well Drilling License Number2'O10 /3 Expiration Date Bureau of 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 ❑ Inactive ❑ Test Hole Detected I Suspected Well Water Contaminant(s) Adjacent property with contamination(Address) Known Soil I Water contaminants at adjacent property_ EXISTING WELL CONSTRUCTION DETAILS ❑ Open Bottom ❑ Gravel Pack ❑ Uncased ❑ Other Well Log copy attached ❑ Yes X No Grout Seal ❑ No ❑ Yes ft below ground surface(bgs) Hole Dlameter Inches Well Conductor Casing O Yes ❑ No Depth of Conduc}tor Casing ft bgs Diameter of Conductor Casing Inches Well Casing Diameter_—inches Total Depth• ft Depth to Water_ it Depth of Casing__ ft bgs DE.STRUM. OV SPECTFICAT70N `•�� Sealing Material from V ft bgs to 0 ft bgs Filler Material from ft bgs to R bgs Well casing to be perforated by one of the following methods: from ft bgs to ft bgs ❑ Mills Knife Number of cuts every k and/or ❑ Explosives❑ Detonating cord ❑ with projectiles every ft ❑ without projectile ❑ Detonating cord and boosters ❑ with projectiles every ft ❑ without projectile ❑ Other Sealin aterlal Neat Cement(94 Ib bag/5-6 gal water) Sand Cement sack mix 17 gal water Bentonite Pellets Bentonite(20%solld! Manufacturer Spec%solids_% Name V Specs on File Specs Submitted Placement Method A Pumped Free Fall Other Seal Completion Complete with Mushroom Cap ft bgs Complete to Existing Surface Pad 1 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. MINIMUM 24 HOUR ADVANCE NOTICE RE01- '"'"TIONS CONTRACTORS SIGNATURE � �I rTLE t{ • p♦ DATE 9—15 I NT ---RECEI ED I - 1J SEp 1 2020 _ L ! i .'•_ �JOAQUI COUNTY - - -�� --�-; --'- - ENVIRON ENTAL - - - - -- --; !— ---- M T — -!-= HEALTH DE R ENT _ DEPARTMENT USE ONLY Application Accepted By Deft OvZU Area 7Z�T Destruction Inspection By R y Date Employee ID# COMMENTS PE SC Received Check#/ Amount Date Permit/ Invoice# Well ID# Codes Info Cash Remitted Servlce Re uest# ilk, i EHD 43-08 WELL DESTRUCTION PERMIT 1015107