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WELL DESTRUCTION PERMIT PUBLIC WATER SYSTEM ❑Yes ❑No SAN JOAOUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1866 East Hazelton Avenue-STOCKTON CA 95205-(209)468-3420 NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED r. JOB ADDRESS CrTY/7jp NNW GAV 19-900 CROSS ET APN D90O PARCEL SIZE NLILAND USE APPLICATION t c_ OWNER PHONE Tol �Y04C ✓00000 OWNER ADDRESSL CrTY/STATEMP V Ar! NV v CONTRACTORftaPNDNE • 10411-0 CoNTR TOR ADDRESS A 10a0.'rC Crry/STATEZP M, Gd OWKI C-57 WELL DRILLING LICENSE NUMBEn 'V�l�� EXPIRATION DATE04-W-Inl _ PERFORATION CONTRACTOR PHONE PERFORATION CONTRACTOR ADDRESS CrrY/STATE/ZIP ❑ C-57 Well Drilling License Number Expiration Date ❑ 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 Sherill-Coroner Explosives Application and Permit License Number Expiration Date ❑ California Occupational Safety Health-Blaster License Number Expiration Date REASON FOR DESTRUCTION "A Dry ❑ Replacement Well ❑ Caved In ❑ Pit Well ❑ Inactive ❑ Test Hole Detected/Suspected Well Water Contaminants) Adjacent property with contamination(Address) Known Soil/Water contaminants at adjacent property EXISTING WELL CONsTRUCTK)N DETAILS 'V[ Open Bottom ❑ Gravel Pack ❑ Uncased ❑ Other _ Well Log copy attached ❑ Yes )I No Grout Seal ❑ No ❑ Yes It below ground surface(bgs) Hole Diameter inches Well Conductor Casing❑ Yep ❑ No Depth of Conductor Casing _h bg Diameter of Conductor Casing inches Wall Casing Diameter inches Total Depth-b--� ft Depth to Water h Depth of Casing _IT bgs DESTRUCTION SPECFICATIO rn A Sealing Material from _(eft bgs to h bgs Filler Material from ft bgs to h b EN T Well casing to be perforated by one o1 the following methods: _._ from . ___It bgs to h bgs C /Irl'V L D ❑ Mills Knife Number of cuts every tt and/or C ❑ Explosives❑ Detonating cord ❑ with projectiles every if ❑ without projectile A ❑ Detonating cord and boosters ❑ with projectiles every h ❑ without projectile G 25 2020 ❑ Other � Sealing Material Neat Cement(941615895-6 gal wafer) Sand Cement sack mix/7 gal water BentoA(e e� QU P"6Bentonite(20%solids) Manufacturer Spec%solids_ _ _9; Name _ Specs on File Specs j CN COUNTY ementMeth x Pumped Free Fall Other LT ENTgL Seal Completion( Complete With Mushroom Cap 3 It bgs , Complete to Existing Surface Pad R T MENT 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. qv M\'^NIM H DVANCE NOTICE REQUIRED FOR INSPECTIONS CONTRACTORS SIGNATURE�j T.DT11W WNW DATE PC !_ t i 1 I i I EH DEPAR MENT USE ONLY (}�� Application Accepted By G Z— Dale N9WO Area e_ Destruction Inspectlon By Date Employee ID# _ COMMENTS h�F f(Jf F t:51 t�G C �F(t/ / '�. lvbl naf q17 �bt�/YCf III Idf n fef4e Ccc In' t V Q- l r - ' 'a-c �-'— - V TT1J lC PE SC Received Checks/ Amount Date Permit/ Invoice a Well IDs Codes Info 8 ash Remitted Service Request If `3C,& c70 5� SIS N� .0 EHD43-DB I/,Z�/�D 2 2 WELL DESTRUCTION PERMIT