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WELL DESTRUCTION PERMIT PUBLIC WATER SYSTEM ❑Yes 0 N <br /> 1868 East Hazelton Avenue-STOCKTON CA 95205-(209)468.3420 <br /> EXPIRES 1 YEAR FROM DATE ISSUED <br /> SAN JOAGUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENTCALL 209 953-7697 FOR INSPECTIONS ,^ <br /> NON-REFUNDABLE PERMIT CrrY/ZIP W a <br /> a ���� APPLICATION ° <br /> Jos ADORES. —0100 0 W v PARCEL SIZE _CND USE �� A <br /> APN <br /> GROSS STREET ' PHONE <br /> OWNER CRY/STATrJZZIP <br /> OWNER ADORES. PHONE <br /> S n <br /> CONTRACTOR CITyt$TATERIP <br /> CONT <br /> (RACTOR ADDRESS ExPIRATION DATE <br /> 9 C-57 WELL DRILLING LICENSE NUMBER <br /> I, PHONE <br /> PERFORATION CONTRACTOR <br /> PERFORATION CONTRACTOR ADDRESS CITNumber <br /> E/ZIP <br /> N <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 ❑ Replacement Well ❑ Caved In ❑ Pit Well ❑ Inactive ❑ Test Hole <br /> Detected/Suspected Well Water ontaminant(s) <br /> Adjacent property with contamination(Address) <br /> Known Soil/Water contaminants at adjacent property <br /> EXISTING WELL CON N DETAILS ❑ Open Bottom Gravel Pack ❑ Uncased ❑ Other <br /> Well Log copy attached ❑ YesNo Grout Seal ❑ No C1 Yes___It below ground surface(bgs) Hole Diameter inches <br /> duc r <br /> Well Conductor Casing❑ Yes No Depth of ConCasing h bgs Diameter of Conductor Casing inches <br /> Well Casing Diametet �inches Total Depth _It Depth to Water h Depth of Casing It bgs <br /> DESTRUCTION SPECIFICATION `gr1�'r <br /> Sealing Material from —W—ft bgs to Ui ft bgs Filler Material from it bgs to ft bgs <br /> Well casing to be Perforated by one of the following methods: fromit bgs to ft bgs <br /> ❑ Mills Knife Number of cuts every ft and/or <br /> ❑ Explosives❑ Delonating cord ❑ with projectiles every it ❑ without projectile <br /> ❑ Other ❑ Detonating cord and boosters ❑ with projectiles every it without projectile <br /> SO <br /> Ing Material : Neat Cement(94/b bag/5-6 gal water) Sand Cement sack m!x!7 gal water I Bentonite Pellets <br /> Bentonite(207 solids) i Manufacturer Spec%solids-7 Name L Specs on File J Specs Submitted <br /> Placement Method X Pumped n Free Fall f Other <br /> Seal Completion Complete with Mushroom Cap It bgsi 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 /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN <br /> JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> WORKERS COMPENSATION LAWS. COMPLIANCE WITH ALL <br /> IV <br /> MPMUMXHOU ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br /> CONTRACTOpa Si6NATlaiE TITLE� y DATE-K <br /> FE IN T <br /> - E TIL— <br /> yL/� DEPARTMENT USE ON(.Y <br /> Application Accepted By DateJ7Ji�� Area %C <br /> Destruction Inspection By C` i l a 1 . '� <br /> '�{ �� ` Date t,� Employee IDs DA <br /> COMMENTS <br /> PE Into Received Amount Permlt/ <br /> Codes Info Cas emitted Date Service Request <br /> I Invoice M well ID# <br /> f- 5 <br />