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1 i . <br /> WELL DESTRUCTION PERMIT <br /> PUBLIC WATER SYSTEM ❑Y,, ❑Pk> <br /> SAN JOAGUIN 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 /> JOB ADDRESS —CITY/ZIP /� N, GW <br /> aJ <br /> CROSS STREET APN ZOI- O O-ll'/O PARCEL SIZE"1 <br /> LAND USE APPLICATION# o <br /> WINM <br /> OWNER IF <br /> 1l 1 PHONE <br /> OWNER ADDRESS V O �/ CITY/STATE/ZIP <br /> CONTRACTOR f PHONE ' X22 iq <br /> CONTRACTOR ADDRESS m tWV'>K <br /> CITY/STATE/ZIP <br /> IY C-57 WELL DRILLING LICENSE NUMBER EXPIRATION DATE <br /> PERFORATION CONTRACTOR PHONE <br /> PERFORATION CONTRACTOR ADDRESS CrTY/STATE/ZIP <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 Safety Health-Blaster License Number Expiration Date <br /> REASON FOR DESTRUCTION id Dry ❑ Replacement Well ❑ Caved In ❑ Pit Well <br /> ❑ Inactive ❑ Test Hole <br /> Delecled'Suspected Well Water Contaminant(s) <br /> Adjacent property with contamination(Address) <br /> Known Soil/Water contaminants at adjacent property <br /> EXISTING WELL CONSTRUCTION DETAILS ❑ Open Bottom Gravel Pack ❑ Uncasad ❑ Other <br /> Well Log copy attached ❑ Yes COY PJo Grout Seal ❑ No ❑ Yes_ it below ground surface(logs) Hole Diameter inches <br /> Well Conductor Casing❑ Yvs ❑ No Depth of Cond ctor Casing__. it s Diameter of Conductor Casing inches <br /> I — <br /> Well Casing Diameter—V- -inches Total Depth- f( Depth to Water it Depth of Casing__-__It bgs <br /> DESTRUCTION SPECIFICATION 1 <br /> Sealing Material from �_Qft bgs to_ ft bgs Filler Material--------_from --ft bgs to _ h bgs <br /> Well casing to be perforated by one of the following methods: from_______R bgs to--- ft bgs <br /> ❑ Mills Knife Number of cuts every it 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 Neat Cement(94 1b bagl5-6 gal water) Sand Cement sack mix/7 gal water yBentonite Pellets <br /> Bentonite(20%solids) ! Manufacturer Spec%solids—% Name Specs on File Specs Submitted <br /> Placement Method - Pumped ' Free Fall Other <br /> Seal Completion X Complete with Mushroom Cap _If 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 /> M`I�II(I7,{�� {I H ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br /> CONTRACTORS SIGNATURE \1 , TITLE I Idly —.-.-DATE-1)q.1)4 <br /> -t - <br /> P 10 <br /> CIA-At <br /> 2020 <br /> - - - - -- - V) vm"- NTY <br /> Nr <br /> i <br /> I <br /> DEPARTMENT USE ON Y <br /> Application Accepted By Z Data 9 Area <br /> Destruction Inspection ByJ ''JJ — Dale �2 �W Employee ID# <br /> COMMENTS J 8/ / y If�! - W'I t VI C <br /> PE SC Received Check#/ Amount Date Permit/ Invoice# Well ID# <br /> CodesInfo B ash Remitted ice Re uest 1/ <br /> 373 c 1 s4- 9r <br /> EHD 43-08 /) �I/ -Al WELL DESTRUCTION PERMIT <br />