WP0041275 - Laserfiche WebLink

Home Browse Search

WELL DESTRUCTION PERMIT PUBLIC WATER SYSTEM ❑Yes ❑No SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPT 1868 East Hazelton Avenue-STOCKTON CA 95205.6232-(209)468-3420 NON-REFUNDABLE PERMIT CALL 209)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED JOBADDRESS 10904 E. Tokay rninn,'+Rd Crrr/ZrP T.nii 95240 CROSS STREET St Rt H i qh wa�, A$ APN�'r%.S! ('}'V b✓ PARCEL SIZE Ll°^LAND USE APPLICATION# e A OWNER Mary MOC)rP PHONE N OWNER ADDRESS P_n. Rnv 9_73 CrrY/STATE/ZIPLTnc1Pnrf'A A5236 CONTRACTOR PttrviannP nrillQss' INC PHONE-209 887_3554 CONTRACTOR ADDRESS 17707 Highway 26 p^� CrrY/STATEMPLinden,_CA 9523E C-57 WELL DRILLING LICENSE NUMBER -q77 EXPIRATION DATE ry Sk+u T 3I ao�/ '/ PERFORATION CONTRACTOR -A PHONE PERFORATION CONTRACTOR ADDRESS CfTY/STATE/ZJP I ❑ C-57 Well Drilling License Number Expiration Date 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 Contaminant(s) =J;V--- Adjacent property with contamination(Address) Known Soil/Water contaminants at adjacent property_ ExISTING WELL CONSTRUCTION DETAILS Open Bottom ❑ Gravel Pack ❑ Uncased ❑ Other _ Well Log copy attached ❑ Yes No Grout Seal ❑ No ❑ Yes ft below ground surface(bgs) Hole Diameter- -inches Well Conductor Casing❑ Yes No Depth of Conductor Casing ft bgs Diameter of Conductor Casing inches Well CasingDiameter inches Total Depth g p 9f _ft Depth to Water_NjFf it Depth of Casing_ it bgs DESTRUCTION SPECIFICATION Sealing Material from 0 ft bgs to 99 ft bgs Filler Material from 0 ft bgs to —ftbgs Well casing to be perforated by one of the following methods: from It bgs to It bgs ❑ Mills Knife Number of cuts every-_,, ft and/or _ ❑ Explosives❑ Detonating cord ❑ with projectiles every it ❑ Without projectile ❑ Detonating cord and boosters ❑ with projectiles every It ❑ without projectile ❑ Other _ Sealing Material Neat Cement(94 Ib bag/5-6 gat water) Sand Cement 10.3 sack mal 7 gal water Bentonite Pellets Bentonite(20%solids) Manufacturer Spec%solids_% Name Specs on File Specs Submitted Placement Method Pumped Free Fall Other Seal Completion Complete with Mushroom Cap 3 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. MINIMUM 48JiQUR ADVANCE NOTICE REQUIRED FOR INS ECTIONS T. CONTRACTORS SIGNATURE ii� ,,..11Jt{=dr?�6b DATE � I CFS V - - = sqN E ?8 020 - = - �_ _ 2 �- -- - - H EN V/ p U)N�� — - EALTy HENT UNTY 4 PgRT AC r o �- NT DEPARTMENT USE ON Y f' /y Application Accepted By �' L. Date a y d L V Area y -I Destruction Inspection By CileCA Date IEmploy.1D# COMMENTS I hP J the C.-SIP I (list be -leered 'a I�IIm15t�SIP pnV iD51. 7— PE PE SC Received Check#/ Amount Date Permit/ Invoice# Well ID# Codes Info B Cash Remitted rvice Re uest# 37 3 n n 'L , /I revised4/1 41184 14118 ( / `!! l! / / � WELL DESTRUCTION PERMIT