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1' <br /> WELL DESTRUCTION PERMIT <br /> PUBLIC WATER SYSTEM ❑Yes 0 NO <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 Eget 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 /> CrTy ZIP <br /> qL <br /> JOB ADDRESS <br /> c <br /> APN PARCELS <br /> CROSS STREET ¢ LL�AND USE APPLICATION <br /> # c <br /> PHONE <br /> OWNER <br /> Cm/STATFJZIP <br /> OWNER ADDRESS ,` , <br /> CONTRACTOR L�1 r ' PHONE 0 1� <br /> COCONTRACTOR ADDRESS CITY/STATE/ZIP lCf <br /> v C� <br /> :�r,7 <br /> y� C-57 WELL DRILLING LICENSE NUMBER EXPIRATION DATE <br /> PERFORATION CONTRACTOR PHONE <br /> PERFORATION CONTRACTOR ADDRESS CrrY/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 Dry [I Replacement Well ❑ Caved In ❑ Pit Well ❑ Inactive 11 Test Hole <br /> Detected/Suspected Well We r ontaminant(s) <br /> Adjacent property with contamination(Address) <br /> Known SOIUWater contaminants at adjacent property <br /> EXISTING WELL CONS ❑ Open Bottom Gravel Pack ❑ Uncased ❑ Other _ <br /> Well Log Copy attached ❑ Yes No Grout Seal Cl No ❑ Yes__it below ground surface(bgs) Hole Diameter inches <br /> Well Conductor Casing❑ Yes ❑ No Depth Of Con ctor Casing it s Diameter of Conductor Casing inches <br /> Wall Casing Dlameter� H - inches Total Depth Depth to Water Q Depth of Casing <br /> it bgs <br /> DFSTRV T1914PE FI AT r I <br /> Sealing Material from It bgs to 01 ft bgs Filler Material_ from it bgs to ft bgs <br /> Well casing to be perforatene by oof the following methods — g <br /> from ft bgs to_ it bgs <br /> ❑ Mille Knife Number of cuts every h and/or <br /> ❑ Explosives❑ Detonating cord ❑ With projectiles every it ❑ without projectile <br /> ❑ Other ❑ Detonating cord and boosters ❑ with projectiles every ft ❑ without projectile <br /> al' g Material . Neat Cement(94 Ib bag/5-6 gal water) Sand Cement -_sack mixi7 gal water Bentonite Pellets <br /> Bentonite(20 U solids) i Manufacturer Spec%solids Name _ L Specs on File I Specs Submitted <br /> PI ce Int Method " Pumped Free Fallz 1 -I Other <br /> Seal Completion Complete with Mushroom Cap �Llit bgs L. 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 /> IM M HOU ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br /> CONTRACTORS SIGNATURE TITLE DATE 0 /L//� - <br /> FD <br /> - <br /> 282020 <br /> -T a U)N C <br /> r°�N ry <br /> -- — - - — p4Rr 4E r <br /> I <br /> I - <br /> I <br /> DEPARTMENT USE ON Y <br /> Application Accepted By Z= t_ 1 r Date `>� d-F -0, 0 Area y �/ <br /> Destruction Inspection By_ s t.�1 k: La+�-- � 1, Date VA`'O 10`lL <br /> Employee IDN! <br /> COMMENTS Idt' Irl�rt!a:' r ) ,, T t ( , <br /> —,_nl4lVI miGh ie,ft-r (ark Srcr1)'r:55 ' <br /> PESC Rexived Check#/ Amount Date Permit/ <br /> Codes Into ash Remitted c R # Invoice# Well ID# <br /> EHD 43-0e WELL DESTRUCTION PERMIT <br />