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WELL DESTRUCTION PERMIT N&e-\-V% W e L l PUBLIC WATER SIBTEM ❑Yes XND SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPT 1868 East Hazelton Avenue-STOCKTON CA 95205.6232-C(2,09)468.3420 NON-REFUNDABLE PERMIT CALL 209 953-7651 i=OR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS +; CITYMP-575 aoc 14fie rl C,15Z,115 ,y CROSS STREET w Q\.�1 APN 1 I O I PARCEL SIZE I TILAND USE APPLICATION# OWNER Cr'r WOrt.4d L %A Co L-LC PHONE01I(0- L40 -837-5 - OWNER ADDRESS '7 V On YdCnXcE1S2kVC-, G.. CIT`//STATEZP G CONTRACTORl\ • PHONE CONTRACTOR ADDRESS L CITY/STATEMP'V'%-A C5 CR 9536 V C-57 WELL DRILLING LICENSE NUMBER 2,� y0 CJ 13 EMRATON DATE PERFORATION CONTRACTOR PHONE PERF RATION CONTRACTOR ADDRESS - - "' CrrY/STATE2JP Q C-57 Well Drilling License Number 2A0 13 Expiration Date 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 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 ExisnNG WELL CONSTRUCTION DETAIL Open Bottom ❑ Gravel Pack ❑ Uncased ❑ Other Well Log copy attached 11Yes .No Grout Seal ❑ No ❑ Yes It below ground surface(bgs) Hole Diameter _inches Well Conductor Casing❑ Yes N 40 Depth of Conductor Casing ft bg Diameter of Conductor Casing _inches Well Casing Dlameter��Inches Total Depth2a&It Depth to Water n �It Depth of Casing JIM_It bgs DGSTRUCrrON SPErWICATION '�;t 3 Sealing Material from _44_ftbgs t It bgs Filler Material Fro ft It bgs to 22.3-ft bgs Neil Easing to be perforated by one of the followingfrom ft bgs to Q r It bgs �,"ills Knife Number of cuts everym thod ft and/or Explosives❑ Detonating cord ❑ With projectiles every ft ❑ without projectile ❑ Detonating cord and boosters ❑ with projectiles every It ❑ without projectile ❑ Other Sealing Material Neat Cement(94 Ib bag/5-6 gal water) Sand Cement �y'1�sack mix/7 gal water Bentonite Pellets Bentonite(201VI.solid Ufacturer Spec%solids_% Name Specs on File Specs Submitted Placement Method PLO Free Fall S Other Seal Completion Complete"MItIrMeLahroorn Cap(y j y G 7 It 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. 1 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 REQUIRE F NS`P'ECTIONS A CONTRACTORS SIGNATURE - .TLE V r P• DATE 1O -2,'t-Z — 5 A -achivl - ►====I L' J _ - -- -- _I - + 1 r --I A - - -- - - -- — -- - -. _L - -- — DEPARTMENT USE ONLY7 PJJ L� Application Accepted By 'fDate a dwob Area HPN N CO ry Destruction Inspection By Date Employee ID# TSL C?MMENTS VQ 7 1 Fl h t+D t: raSti t I �)T L N C. — , 11417/01o PE SC Received AmountData Parmk/ Invoice# Well ID# Codes Info B Remitted ice Requqst# EHD 43-08 WELL DESTRUCTION PERMIT 10/5107