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WELL DESTRUCTION PERMIT PUBLIC WATER SYSTEM ❑YesXNO SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPT 1868 East Hazelton Avenue-STOCKTON CA 95205.6232-(209)468-3420 NON-REFUNDABLE PER IT 39 953-7697 FOR INSPECTII_ EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESSCrrY21P S+ASO c�&Q�C A 952-0 b 9 CROSS STREET *r APN I�1y 7-Z3- 0 7-� PARCEL SIzE2/{BLAND USE APPLICATION# OWNER ) PHONE I 4-109-[)aVJHqnJq OWNER ADDRESS<7 CITY/STATEIZIP Z1666 9X-A W-4l ,s1C - �i CONTRACTOR S C. PHONE 545 -II IB 5 �S+ITC Vg. CONTRACTOR ADDRESS ` CRVISTATE/ZIPAesto, A"14 &4(. C-57 WELL DRILLING LICENSE NUMBER t' EXPIRATION DATE� �1e�•, •✓�� PERFORATION CONTRACTOR PHONE PERF ATION CONTRACTOR ADDRESS CRY/STATEZP C-57 Well Drilling License NumberZ90$) Expiration Date '30 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 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 ❑ Uncesed ❑ 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 oLCtsVuctor Casing ft bgs Diameter of Conductor Casing inches _�Well Casing Diameter __.inches Total Dep'l .i54 ft Depth to Water_ it Depth of Casing ft bgs Sealing Material from ft bgs to t^f ft bgs Filler Material from it bgs to It bgs Well casing to be perforated by one of the following methods: from ft bgs to ft bgs ❑ MillsKnife Number of cuts everyft and/or ❑ Explosives❑ Detonating cord ❑ With projectiles every ft ❑ without projectile ❑ Detonating cord and boosters ❑ With projectiles every ft ❑ Without projectile ❑ Other Seali Material Neat Cement(94/b bag/5-6 gal water) Sand Cement sack mix/7 gal water Bentonite Pellets Bentonite(20%soli Manufacturer Spec%solids_% Name Specs on File Specs Submitted Placement Method 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 I AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION LAWS. MINIMUM 24 HOUR AD�VAAMrFr`MOTIC J�� 0= - _ CONTRACTORS SIGNATURE � UAL�[, � TITLE l�\/I 1, 1 • P DATE •Ary S- -Zo � I Afr I — _ �SES 2 9 020 SAN JOAQ VjRONIyFNCpN7Y - -- EALTN N AL 'RTAENT DEPARTMENT USE ON Y 6 yam' L Application Accepted By Date 43JG;V� Area Destruction Inspection By C y�. h 3 Date N 1014) Employee lD# DJQI COMMENTS ]nit P"C _ijU ^b b�l� ►^�� F1 PE SC Received ChackNl Amount Dat Permitl Invoice# Well ID# Codes Into B Cash Remitted I e Re ues # 1-1373 Ifo ► I 119 s - 74P V WMA) EHD 43-M WELL DESTRUCTION PERMIT 10/5107