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WELL DESTRUCTION PERMIT PUBLIC WATER SYSTEM❑Yes 0 N <br /> 1868 East Hazeiton Avenue.STOCKTON CA 95205-(209)468-3420 <br /> CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> SAN JOAOUIN COUNTY EHymONMENTAL HEALTH DEPARTMENT <br /> NON-REFUNDABLE PERMIT CIyRjp F <br /> JOB ADDRESS `1� a O PARCEL SrzE . �qAUSE APPLICATIIONN�--�� p <br /> �N2AG-I�#U—OIG end "IVl 3��Y1__ <br /> CROSS STREET ' PHONE <br /> OWNER CRY/STATFIZIP <br /> IQ� <br /> 0W <br /> WrgR ADDRESS PHONEIhI r77 -tonna oca-n ('A A5�51 <br /> CONTRACTOR Crry/STATEMP n <br /> CONTRACTOR ADDRESS ExpIRATiON DATE v , <br /> 9 C-A57 WELL DRILLING LILEI6E NUMBER <br /> /�Q <br /> /, PHONE <br /> PCRFORATION CONTRACTOR <br /> PERFORATION CONTRACTOR ADDRESS CITY/STATE/ZIP <br /> O 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 Sherlif-Coroner Explosives Application and Permit License Number Expiration Date <br /> O California Occupational Safety Health-Blaster License Number Expiration Date <br /> REASON FOR DESTRUCTION Dry ❑ Replacement Well ❑ Caved In ❑ Pit Well ❑ Inactive ❑ Test Hole <br /> Detected/Suspected Well Water ontaminant(s) <br /> Adjacent property With contaminabon(Address) <br /> Known SOIVWater contaminants at adjacent property <br /> EXISTIK WELL Cn AI ❑ 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❑ Y s No Depth of Cond c r Casing ft bgs Diameter of Conductor Caning irKhes <br /> Wall Casing Dlametet�_Inches Total Depth It Depth to Water it Depth of Caving it bgs <br /> DESTRUCTION SPECIFICATION {�I <br /> Sealing Material from - .�Lft bgs to DI It bgs Filler Material from _R bgs to it bgs <br /> Well caning to be gerfont d by one of the following methods- from R bgs to If bgs <br /> ❑ Mills Knife Number of cuts every ft and/or <br /> ❑ Expiosives❑ Detonating cord ❑ with projectiles every tt ❑ without projectile <br /> ❑ Other 11Detonating cord and boosters ❑ with projectiles every it 13without projectile <br /> SfjIng Material r Neat Cement(94 16 bag/5-6 gal water) Sand Cement_ sack mix/7 gal water ! Bentonite Pellets <br /> Bentonite(20%solids) a Manufacturer Spec%solids_% Name L Specs on Fla 7 Specs Submitted <br /> P Acement Method X Pumped n Free Fall I -I Other <br /> Seal Completion Complete With Mushroom Cap _ _it bgs I 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 /> 7D <br /> MMWMXIiOU ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br /> CONTRACTORS SIGNATURE TITLE A DATE <br /> i - - - E T LUp <br /> - <br /> _ <br /> _4 4�._ __ <br /> / DEPARTMENT USE ON Y <br /> Application Accepted By � L/� Date woo Area `A <br /> Destruction Inspection By Date Employee IDN DA <br /> COMMENTS <br /> PE Sc Race ivad Amount PermW <br /> Codes Info �Ramitted Date Service R Heat a Invoice t Well IDs <br /> l <br />