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WELL DESTRUCTION PERMIT �/ SO V�L` � _/c'` 1 PUBLIC WATER SYSTEM E]Yes U[No SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPT ` 1868 East Hazelton Avenue-STOCKTON CA 95205-6232--(209)468-3420 NON-REFUNDABLE PERMIT (� t - (209)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS OO ^ T• 1 p CITY1ZIP C�7Q(n 95?-IG CROSS STREET N.ek 1'C r`.r-1 ". APN 11r]L-It) 09 PARCEL SIZE L(A►ND USE APPLICATION#` OWNER-Q:\ Nafc.a.l Lar%J Cn• LLC- PHONE II,-„„Z�, 7O �.�f��✓�V J p OWNER ADDRESS y3Lt?j \!on 1kowm4n. &V C.,Ste- CITY/STAAT,E/ZIP�r CT��/t CONTRACTOR tnnin�s 6a r6%1 ..DI-i Ili ghCo- �O PHONE7�]'5- IL815 LI CONTRACTOR AD DRESS Il 0 L&a. Cj ”, J -rAC' CrtY/STATE/ZIPMcdeta c C-57 WELL DRILLING LICENSE NUMBER 2010'5 13 EXPIRATION DATE 5-3 t PERFORATION CONTRACTOR PHONE PERFORATION CONTRACTOR ADDRESS CITY/STATE/ZIP q- C-57 Well Drilling License Number L / Expiration Dat / _ 2- C 18Bureau 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 Safely 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 DETAILS Open Bottom ❑ Gravel Pack ❑ Uncased ❑ Other Well Log copy attached ❑ Yes-7(zo Grout Seal ❑ No ❑ Yes it below ground surface(bgs) Hole Diameter inches Well Conductor Casing r' "-- ❑ No Depth of Conductor Casing ft bgsDiameter of Conductor Casing inches Well Casing Diameter_,L4 aches Total Depth 21 to ft Depth to Water-- .// it Depth of Casing fib-ft bgs DESTRL('TION SPECIFICATION �I[ �t / Sealing Material from �� _it bgs tq_ _6_ filings uFiller Material from t�ft bgs to f.�.ljft bgs ell casing to be verforated by one wing methods, - Q ft bgs to _ft bgs Mills Knife Number of cuts every ftand/or ❑ Explosives❑ Detonating cord ❑ with projectiles every ft ❑ without projectile ❑ Detonating cord and boosters ❑ with projectiles every ft ❑ without projectile ❑ Other Sealing Material Neat Cement(94 lb bag/5-6 gal water) Sand Cement i J3• sack mix/7 gal water Bentonite Pellets Bentonite(20%solids anufacturer Spec%solids_% Name Specs on File Specs Submitted Placement Method Pum a Free Fall Other Seal Completion Complete with Mushroom Capn&-L)JG 5b;1 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 QADeV/Af',' 'E NOTICE R QUIRED FOR INSPECTIONS CONTRACTORS SIGNATURE Y+�.�y.� rTL DATE I I t-- �Px - N gQUI DEPARTMENT USE ON Y 4 a/vq��rq� 7Y Application Accepted ey Date v o�� Area GI pp M ADestruction Inspection By Date 1 v � Employee ID# COMMEN S CkA ` PE Sc Received hec Amount Permit/ Invoice# Well ID# Codes Info B Date Remitted Service Re nest 43 `1 EHD 43-08 WELL DESTRUCTION PERMIT 10/5/07