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WELL DESTRUCTION PERMIT / <br /> PUBLIC WATER SYSTEM ❑Yes flo <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 East Hazelton Avenue-STOCKTON CA 95205 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT <br /> /CALL 209 953-7697 FOR INSPECTIONS �EX.�Pc-I�RgES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS_2 55� t- h r CiTY/ZIP 7�✓' / '� <br /> CROSS STREET = ' <br /> \V "Z)APN �s� PARCEL S 7771LAND USE APPLICATION# <br /> OWNER <br /> OWNER ADDRESS / �/ k",, 1' /W-'`CITY/STATERIP s✓�' iii <br /> CONTRACTOR /�L�1L. PHONE <br /> yi/�_/ <br /> CONTRACTOR ADDRESS' CITYISTATE/ZIPy'1 '�✓ p �—a <br /> 4(1 C-57 WELL DRILLING LICENSE NUMBER 7 EXPIRATION DATE <br /> PERFORATION CONTRACTOR �4 PHONE �~ <br /> PERFORATION CONTRACTOR ADDRESS CITY/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 Mi Replacement Well ❑ Caved In ❑ Pit Well ❑ Inactive ❑ Test Hole <br /> Detected/Suspected Well Water Contam" ants) <br /> Adjacent property with contamination(Address) <br /> Known Soil/Water contaminants at adjacent property .._.__................._.-_. <br /> EXISTING WELL CONSTRUCTION DETAILS /1y Open Bottom ❑ Gravel Pack ❑ Uncased ❑ Other _ .._...._............................_ <br /> Well Log copy attached ❑ Yes ❑ No Grout Seal ❑ No ❑ Yes__It below ground surface(bgs) Hole Diameter_.._........................._inches <br /> Well Conductor Casing ❑ Yes ❑ No Depth of Conductor Casing ,............_....__...........___ft bgs Diameter of Conductor Casing___ inches <br /> t L f Depth of Casing <br /> ......_..It bgs <br /> Well Casing Diameter_t� inches Total Depth_ 1>� ft— Depth to Water__..,..... ............... t p 9-....___.. <br /> DESTRUCTION SPECIFICATION = <br /> Sealing Material from .,>`.... _ ...........__ft bgs to _. -__ ft bgs Filler Material ._,____,.__......._.___.._......._...... from_.. ft bgs to ft bgs <br /> Well casing to be perforated by one of the following methods: _.............. .._.._.._. from_�_.- ____It bgs to It bgs <br /> ❑ Mills Knife Number of cuts every ft and/or— <br /> ❑ Explosives ❑ Detonating cord ❑ with projectiles every __. ._ ft ❑ without projectile <br /> ❑ Detonating cord and boosters ❑ with projectiles every ft ❑ without projectile <br /> ❑ Other -.--- <br /> Sealing Material Neat Cement(94 lb bag,15-6 gal water) Sand Cement &r. _._..__.sack mix/7 gal water Bentonite Pellets I <br /> Bentonite(20%solids) Manufacturer Spec%solids.__._....% Name .._ ._._ _ Specs on File Specs Submitted <br /> Placement Method Pumped Free Fall y Other <br /> Seal Completion jJ 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 /> M H ANCE NOTICE REQUIRED FOR INSPECTIONS <br /> i 1 <br /> CONTRACTORS SIGNATURE "A// TITLE 1' � DATE�! 1 <br /> 1 f <br /> 46 <br /> 07 r <br /> •�.'HCl �.• . _ ..____ �__._ . 1_.._ _._. ..+k._ <br /> rrte�•. 1 <br /> _ <br />