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WELL DESTRUCTION PERMIT PUBLIC WATER SYSTEM ❑Y-XW SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPT 1868 East Hazelton Avenue-STOCKTON CA 95205.6232��/-(2209)468-3420 1 NON-REFUNDABLE PERMIT 209 953-7697 FOR INSPECTK-. EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS .7. VA 6\ • CITY21P� �yy�(Q&'C 0Q '9515371 CROSS STREET Ira M"ll PARCEL SI�ZEV LAND USE APPLICATION# O F7 OWNER �� PHONE ' 5\0-1195 G✓- { Y C I OWNER ADDRESC Oii CRVISTATEZP OQ KIC1I t.CA 9SN CONTRACTORf\i 1 1 PHONE CONTRACTOR ADDRESS 1 CRY/STATE/ZIP tntd C CA 95,J C-57 WELL DRILLING LICENSE NUMBER 90 EXPIRATION DATE PERFORATION CONTRACTOR PHONE P RF ATION CONTRACTOR ADDRESS CITYISTATEI7JP C-57 Well Drilling License Number 0 Expiration Dat t 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) Adjacent property with contamination(Address) Known Soil/Water contaminants at adjacent property EXISTING WELL CONSTRUCTION DETAIL ❑ Open Bottom ❑ Gravel Pack ❑ Uncased ❑ Other Well Log copy attached ❑ Yes No Grout Seal ❑ N. ❑ Yes R below ground surface(bgs) Hole Diameter Inches Well Conductor Casing❑ Yes ❑ No Depth ofn ctor Casing ft bgs Diameter of Conductor Casing Inches Well Casing Diameterb8 _ " inches Total Dept - j5t Depth to Water _ _ ft Depth of Casing ftbgs DESTRUCTION SPECIFR ATION Sealing Material from () ft bgs to•150 0 ft bgs Filler Material from _ft bgs to ft bgs Well casing to be perforated by one of the following methods: from It bgs to ft bgs ❑ Mills Knife Number of cuts every ft and/or_ ❑ Explosives❑ Detonating cord ❑ with projectiles every _ft ❑ without projectile ❑ Detonating cord and boosters ❑ with projectiles every ft ❑ without projectile ❑ Other S@aljng Material Neat Cement(94 Ib bag/5-6 gal water) Sand Cement sack mix/7 gal water Bentonite Pellets Bentonite(20%solidManufacturer Spec%solids % Name Specs on File Specs Submitted Placement Method Pumped Free Fall Other Seal Completion Cor4ele,with Mushroom Cap 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 24 HOUR ADVANCE NOTICE REQUIRED FO I PEyLeilS /TfO/�NS 9 CONTRACTORS SIGNATURE • TITLE �/• 1 DATE��V� _ HL SAN oA 02020 HF,q V�RpN)N COIN H pEpqR7 NT I � DEPARTMENT USE ONLY Application Accepted By LL Date 101-3-- dArea Destruction Inspection By 11n,lT _ Date Employee ID# IJIZ COMMENTS PE SC Received Ch Amount Date Permit Invoice# Well ID# Codes Info B ash Remitted ice Request 373 10 11,1XVlWIN, WK T EHD 43-081 f /i��T I�'01, WELL DESTRUCTION PERMIT 10/5107 V 4li 1