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WELL DESTRUCTION PERMIT PUBLIC WATER SYSTEM ❑Yes [:]No SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE 3"0 FL-STOCKTON CA 95202 - (209)468-3420 NON-REFUNDABLE PERMIT CALL(209)953-7697 FOR INSPECT IONS EXPIRES 1 YEAR FROM DATE ISSUED ��NN � JOB ADDRESS CITY/ZIP C1/ .'� (' a CROSS ST ET APN 0S 11 9 0 SR PARCEL SIZE �frLAND USE APPLICATION# o OWNER � I I PHONE OWNER ADDRESS4iTI) CITY/STATE/ZIP Y l L � c� �SaS3 CONTRACTOR PHONE CONT CTOR ADDRESS CITY/STATE/ZIP C-57 WELL DRILLING LICENSE NUMBER ��D �� EXPIRATION DATE PERFORATION CONTRACTOR �— PHONE �— PERFORATION CONTRACTOR ADDRESS CITY/STATE/ZIP 41 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 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) Nd✓'e Kw QL'J0J Adjacent property with contamination (Address) Known Soil/Water contaminants at adjacent property EXISTING WELL CONSTRUCTION DETAILS 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 I( inches Total Depth_ft Depth to Water ft Depth of Casing ft bgs DESTRUCTION SPECIFICATION Sealing Material from hoffQ '^ ft bgs to R 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 R and/or ❑ Explosives ❑ Detonating cord ❑ with projectiles every ft ❑ without projectile ❑ Detonating cord and boosters ❑ with projectiles every ft ❑ without projectile ❑ Other Sealing Material ❑ Neat Cement(94 lb hag/5-6 gal water) ❑ Sand Cement sack mix/7 gal water '53ijBentonite Pellets ❑ Bentonite(20%solids) ❑ Manufacturer Spec%solids % Name ❑ Specs on File ❑ Specs Submitted Placement Method ❑ Pumped 11 Free Fall ❑ Other Seal Completion o' Complete with Mushroom Cap C0,10-1+1 -3__ft bgs Complete to Existing Surface Pad I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. 1 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. MIN UM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSP CTIONS CONTRACTORS SIGNATURE TITLE n DATE / — fit'^O'7 O RF yMFNT E7 J04 2 y 2 sANJo 020 M 'EW/R�N/NCoUN DEPARTMENT USE ONLYt) j�� It? , r Application Accepted By �_ L�Li Date O�Oa Area /J Destruction Inspection ByT �1\C'kika �C\ 1 Date Employee ID# DA COMMS TS Dt�v+H 6 OL-1 ynk>7DwY1 . d00 sem, / nie& cue +o high DE P dodo— F ;S% ) I8 In Gar 1J1b?7 se 1 art tin a Is31rl t price d- e> nmk t�k--'R7 zozo PE SC Received eck# Amount Date Permit/ Invoice# WeI11D# Codes Info B Cash Remitted Service a ues # 373 (- i IRS- 2 "M ItOT'll EHD 43-02-008 Well Destruction Permit 1/27,'200.5