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WELL DESTRUCTION PERMIT <br /> PUBLIC WATER SYSTEM ❑Yes ❑No <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT BOO 6 MAIN STREET-STOCKTON CA 95202-(209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> Ln <br /> JOB ADDRESS ^ G CITY/ZIP <br /> CROSSSTREET ° / APN OY 71720 PARCEL SIiE&QLAND USE APPLICATION# o i <br /> OWNER PHONE <br /> OWNER ADDRESS Crr/STATPJZJP <br /> CONTRACTOR �'• ID'006A,-elle PHONE <br /> CONTRACTORADDRESS '-9- AX I'M CITY(STATE/ZIP / <br /> ❑ C57 WELL DRILLING LICENSE NUMBER -gorrS/zI ExPIRATION DATE /z <br /> f <br /> PERFORATION CONTRACTOR PHONE <br /> PERFORATION CONTRACTOR ADDRESS CITYISTATE/ZIP <br /> ❑ C-57 Well Drilling License Number Expiration Date <br /> ❑ Bureau of Alcohol,Tobacco and Firearms-Users of High Explosives License Number Expiration Date <br /> ❑ CHP Hazardous Material Transportation for Explosives License Number Expiration Date <br /> ❑ San Joaquin County Sheriff-Coroner Explosives Application and Permit License Number Expiration Date <br /> ❑ California Occupational Safety Health-Blaster License Number Expiration Date <br /> REASON FOR DESTRUCTION Dry '❑ Replacement Well ❑ Caved In ❑ Pit Well ❑ Inactive ❑ Test Hole <br /> k'lik- <br /> Detected/Suspected Well Water Contaminant(s) <br /> Adjacent property with contamination(Address) <br /> Known Soil/Water contaminants at adjacent property <br /> ExisTING WELL CONSTRUCTION DETAIL ❑ Open Bottom ❑ Gravel Pack ❑ Uncased ❑ Other t J <br /> Well Log copy attached ❑ Yes ❑ No Grout Seal ❑ No ❑ Yes__ft below ground surface(bgs) Hole Diameter inches <br /> Well Conductor Casing❑ Yes 13 No Depth of Conductor Casing ft bgs Diameter of Conductor Casing inches <br /> Well Casing Diameter inches Total Depth ft Depth to Water ft Depth of Casing_ _ It bgs <br /> DF_8TRUCTION SPECIFICATION QQ // <br /> Sealing Material from ft bgs to�_ft bgs FI[ler Material /dGL/L�rw-r - 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 /> i ❑ Mills Knife Number of cuts every ft and/or _ <br /> ❑ Explosives❑ Detonating cord ❑ with projectiles everyIt ❑ without projectile <br /> ❑ Detonating cord and boosters ❑ with projectiles everyft ❑ without projectile. <br /> ❑ Other _ <br /> Sealing Material ❑ Neat Cement(94 Ib beg/S6 gal water)❑ Sand Cement sack mix/l gal water ❑ Bentonite Pellets <br /> ❑ Bentonite(20%sollds) ❑ Manufacturer Spec%solids_% Name ❑ Specs on File ❑ Specs Submitted <br /> Placement Method ❑ Pumped -:i FreeII ❑ Other <br /> Seal Completion u Complete with Mushroom Cap I ft bgs ❑ Complete to Existing Surface Pad <br /> I 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. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> IIMUMOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br /> CONYRACTORS SIGNATURE TITLE ±re2fDATE/Z-Zed-/0 <br /> _ f 0JL/I <br /> PAYMENT' <br /> - <br /> - SNN�OAOUI COEINTY <br /> { ENVIAONMENiAL I' <br /> _ t <br /> -TF- <br /> 1 <br /> DEPARTMENT USE ONLY <br /> Application Accepted �! Date Y. Area <br /> Destruction Inspection Date <br /> ! Employee ID# <br /> COMMENTS / � 11��� �T/ aGS•t L 39 S 4c�f3tl / -Lyras G��—'7c`C4 , 2;, <br /> PE SC Received Amount Date PermlU Invoice# Weil ID# <br /> Conies Info B Cash Remitted Service Request# <br /> fEHD 43-08 - WELL DESTRUCTION PERMIT <br />