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a f <br /> WELL DESTRUCTION PERMIT <br /> PUBLIC WATER SYSTEM ❑Yes ❑No <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 East Hazelton Avenue-STOCKTON CA 95205-(209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> •r. <br /> JOB ADDRESS 2 CRY21P Q <br /> CROSS STREET > S APNO-W PARCEL S12E-/�r LAND USE APPLICATION M <br /> 4- ft! <br /> OWNER PHONE <br /> OWNER ADDRESS CITYISTATE�IZIIP1CONTRACTOR PHONE !� I ZCONTRA OR ADCITY/STATE/Z1PMi 1 <br /> C_57 WELL DRILLING LICENSE NUMBER I91�g�IZ?� EXPIRATION DATE Z <br /> PERFORATION CONTRACTOR PHONE <br /> PERFORR N CONTRACTOR ADDRESS CrTY7STATEIZJP <br /> C-57 Well Drilling License Number Expiration Date <br /> ❑ Bureau of Alcohol,Tobacco and Firearms-Users of High Explosives License Number Expiration Date <br /> ❑ CHP Hazardous Material Transportation for Explosives License Number Expiration Date <br /> ❑ San Joaquin County Sheriff-Coroner Explosives Application and Permit License Number Expiration Date <br /> ❑ California Occupational Safe>Health-Blaster License Number Expiration Date <br /> REASON FOR DESTRUCTION Dry ❑ Replacement Well ❑ Caved In ❑ Pit Well ❑ Inactive ❑ Test Hole <br /> Detected/Suspected Well Water Contaminant(s) <br /> Adjacent property with contamination(Address) <br /> Known SoiUWater contaminants at adjacent property _ <br /> EXISTING WELL CONSTRUCTION DETAIL-S/ ❑ Open Bottom Gravel Pack ❑ Uncased ❑ Other <br /> Well Log copy attached ❑ Yes lJ No Grout Seat ❑ No ❑ Yes___it below ground surface(bgs) Hole Diameter _inches <br /> Well Conductor Casing❑ Yes ❑ No Depth of Condrirt-Casing h Diameter of Conductor Casing inches <br /> ft <br /> Well Casing Diameter inches Total Depth 'oOt_it Depth to Water it Depth of Casing it bgs <br /> DESTRUCTION SPECIFICATION 'l(�1 r <br /> Sealing Material from 1001 It logs to__� it bgs Filler Material__._ _.from_ _it bgs to tt bgs <br /> Well casing to be Perforated by one of the followlna methods: - from___ __ -_._If bgs to _it bgs <br /> ❑ Mills Knife Number of cuts every ft and/or <br /> ❑ Explosives❑ Detonating cord ❑ With projectiles every _ it ❑ Without projectile <br /> ❑ Detonating cord and boosters ❑ with projectiles every _ it ❑ without projectile <br /> ❑ Other ` / <br /> Sealing Material ' Nest Cement(94 1b bao-6 gal water) Sand Cement _sack mix/7 gal water X Bentonite Pellets <br /> Bentonite(20%solids) : Manufacturer Spec%solids___% Name__._ _ Specs on File Specs Submitted <br /> Placement Method Pumped Ii Free Fall t Other <br /> Seal Completion Complete with Mushroom Cap it bgs Complete to Existing Surface Pad <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> LAD <br /> MI U ANCE NOTICE REQUIRED FOR INSPECTIONS t^(/A� /r�l/ <br /> CONTRACTORS SIGNATURE TITLE D._K-_ /.V v <br /> t- <br /> F FNT <br /> ARTT�OU <br /> NTy <br /> MENT <br /> DEPARTMENT USE ONaL ,h <br /> Application Accepted By � Date _ + �a d0�_ `"�_ Area <br /> Destruction Inspection By Date Employee IDM D- <br /> COMMENTS 11� , U�'Ir.� - - .0r. Q I <br /> r <br /> < ,5 (� <br /> /2- r J C V�[ lam► <br /> _q2 a S 7 0 sc <br /> I v i PIR eSS n _ CY�Q-ot�ea S <br /> PE SC Received CheckM/ Amount Permit/ <br /> Codes Info_ Cash Remitted Date Invoice M Well IDM <br /> y373 / — service Re uest M <br /> I QS <br /> LIID 4308 - /��� � WELL DESTRUCTION PERMIT 001 <br />