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MENT EIVED 5 2020 IN COUNTY MENTAL PA RTMENT WELL DESTRUCTION PERMIT PUBLIC WATER SYSTEM 0 Yes 0 No SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 East HazeIton Avenue - STOCKTON CA 95205 - (209)468-3420 NON-REFUNDABLE PERMIT LON V 11-1ILO I f CAI-1 reiLim IJA I t ISSUtl) JOB ADDRESS • ° V t ' V"' Cm/Zip ju 0 * / / I CROSS STREET 1 ilk APN I'PARCEL SIZE LAND USE APPLICATION N OWNER OWNER ADDRESS , ii i PHONE ' / .2-• .1 I • ' l'''' oi h , .,g1 CrTY/STATERIP ' ‘ 'AIN 1 a q 17' . , CONTRACTOR k I al di, ) °V PHONE 1 / . liirMir CONTRACTOR ADDRESS I ' ItlinWarmi Crry/SrsrErtin 11 tr. ' A Fe C-57 WELL DRILLING PERFORATION CONTRACTOR PERFORATION CONTRACTOR 0 C-57 Well Drilling 0 Bureau of Alcohol, El CHP Hazardous 0 San Joaquin County 0 California Occupational LICENSE NUMBER U tig?) W2-2-- EXPIRATION DATE 0 . • ('.) • 202- PHONE ADDRESS Cm/STATE/Zip License Number Expiration Date Tobacco and Firearms - Users of High Explosives License Number Expiration Date Material Transportation for Explosives License Number Expiration Date Sheriff-Coroner Explosives Application and Permit License Number Expiration Date Safety Health - Blaster License Number Expiration Date REASON FOR DESTRUCTION !Dotty 0 Replacement Well 0 Caved In 0 Pit Well 0 Inactive 0 Test Hole Water Contaminant(s) Detected/Suspected Well Adjacent property with Known Soil/Water contaminants contamination (Address) at adjacent property EXISTING WELL CoNsTRuCTioN DETAK4 0 Open Bottom 0 Gravel Pack 0 Uncased 0 Other Well Log copy attached Well Conductor Casing Well Casing Diameter 0 Yes Iii4o Grout Seal Cl No 0 Yes ft below ground surface (bgs) Hole Diameter inches ._ . _ O. liii 0 No Depth of Conc4ctocCasing It Diameter of Conductor Casing inches J ' inches Total Depth 5 ft Depth to Water ft Depth of Casing It bgs DESTRUCTION SPECIFICATKM I Sealing Material from Well casing to be perforateg _ft bgs to _0 _ ft bgs Filler Material from ft bgs to ft bgs by one of the followino methods: from ft bgs to ft bgs 0 Mills Knife Number of cuts every It and/or 0 Explosives 0 Detonating 0 Other cord 0 with projectiles every ft 0 without projectile 0 Detonating cord and boosters 0 with projectiles every ft o without projectile Sealing Material - Neat X Bentonite (20% so Placement Methak Seal Completion Complete Cement (94 lb bag/5-6 gal water) Sand Cement sack mix7 gal water Bentonite Pellets _. Manufacturer Spec % solids ".'. Name Specs on File Specs Submitted Pumped ." Free Fal Other 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. lee MINIMUM)4FjQUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS :SSAMMIV CONTRACTORS SIGNATURE 4... ,fmncnur mut i Lim A riTLEDY1114#/owNW DATE o61-7.7,0 ____ — REC PA) AUG , Lifl HEALTH ENVIROI OE I I•-73-1-141044 . ‘ • ' iii1111111'. ' II itl'A. 4 ell" 1/4 DEPARTMENT USE 0 LY Application Accepted By Destruction Inspection By Date COMMENTS 't 17-51 of r (.1,..612e-a‘ Ti Ce,19 Date oc? 0 PE Codes SC Info Received Meade/ Amount Remitted Date Permit/ S ice R uest # Invoice I Well ID* 1"111 f; 6 14--" O S-02 S k2__.) LIU CV ...--)0 Employee ID# Area LIM WELL DESTRUCTION PERMIT 3agg/1 END 43-06