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WELL DESTRUCTION PERMIT PUBLIC WATER SYSTEM❑Yes No SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPT 1868 East Hazelton Avenue-STOCKTON CA 95205-623 (209)466-3420 NON-REFUNDAEILE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED �p ! N JOBADDRE59 SO QOt I CITY/LP v` CROSS STREET ke Q APN PARCEL S¢E.53 LAND USE APPLICATION# o OWNER I. PHONE G CJ�� + OWNER ADDRE$ 7 I ITY/STA P VFX CONTRACTOR I PHONE AwCONTRACTOR A DRESSIV V VA L CITY/S.tz,p C-57 WELL DRILLING LICENSE NUMBER I CIJU 42 EXPIRATION DATE /A 1 PERFORATION CONTRACTOR PHONE PERFORATION CONTRACTOR ADDRESS CITYISTATE/ZIP C-57 Well Drilling License Number AX"Expiration Dat 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 Contaminants) Adjacent property with contamination(Address) Known Soil/Water contaminants at adjacent property EXISTING WELL CONSTRUCTION DET ILS ❑ Open Bottom ❑ Gravel Pack ❑ Uncased ❑ Other Well Log copy attached ❑ Yes ANo Grout Seal ❑ No ❑ Yes ft below ground surface(bgs) Hole Diameter inches Well Conductor Casing 101 es 13No Depth of Cord ctor Casing ft bgs Diameter of Conductor Casing inches Well Casing Diameterinches Total Depth i f(� Depth to Water tt Depth of Casing ' 3tit bgs DESTRUCTION SPECIFICATION Sealing Material from ft bgs to P:0ftbgs Filler Material It bgs to bgs Well casing to be perforated by one of the following methods: from It bgs to ft bgs ❑ Mills Knife Number of cuts every ft and I or ❑ Explosives❑ Detonating cord ❑ with projectiles every It ❑ without projectile e nati d a o s ers with qro ctitl e without projectile Other 1 9 I !e- ea mg Material944 bag 15-6 gat water Sand Cement sack mix 17 gal water Bentonite Pellets Bentonite(20%solids) M ,Cturer Spec%solids_% Name Specs on File Specs Submitted Placement Method umpedan aFree Fall Other Seal Completion Comp let om Cap It 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. MI H/Qj\JRA/DV'�'NCE NOTICE REQUIRED FOR INSPECTIONS CONTRACTORS SIGNATURE �`yy ' TITLE DATE �� I - - UG 19 2020 — - R p UlN C PgRTMF��y 1 DEPARTMENT USE ONLY Application Accepted By y� Date Srhq/aox) Area / Destruction Inspection By �eruneq UU11" L Date 9116MA Employee ID# DA �1 COMMENTS ��) 7J vJ;7B( 3LGL JfIII, FI f1J' O y ex(e,,vote -P -n dept filial- Proae Jo cror Wa< n .= le It3oy). PE Sc Received Check#/ Amount Date PermlU Invoice# Well ID# Codes Into CaS4 Remitted erviceRequest# 4368 D 4 j>i EHD 43.08 WELL DESTRUCTION PERMIT 1015107 Pym(-,4 + 1117037 -�