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WELL DESTRUCTION PERMIT PUBLIC WATER SYSTEM ❑Yes [)(No SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPT 1868 East Hazelton Avenue-STOCKTON CA 95205-6232-(209)468-3420 NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPEC1 EXPIRES 1 YEAR FROM DATE ISSUED rn 5ZIA N. rar�T S`t M11:161(11-1 c Ca °I S3 3� JOB ADDRESS � CITYIZIP CROSS STREET O Pill 141L AM APN 2-ZS 040� ' PARCEL SIZEt5ZLAND USE APPLICATION# OWNER t0. 11 or r c5 PHONE H O �- C4 6 9 _ OWNER ADDRE S 1 1 tQi CITY/STATEIZJPr�/�', OA w *It,CCA, ,C P1 51 .0 Ail CONTRACTOR 1 1 5 �• PHONE LIS CONTRACTOR ADDRESS I –...,STATE/ZIP O C 5A'0 "153 . 5 XC-57 WELL DRILLING LICENSE NUMBER �L�]O EXPIRATION DATE _9 1—2L2— PERFORATION CONTRACTOR PHONE PERTTION CONTRACTOR ADDRESS CITY/STATE21P p C-57 Well Drilling License Number Q t7 / 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 Califomia 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) Pit 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 ❑ No Grout Seal ❑ No ❑ Yes ft below ground surface(bgs) Hole Diameter inches Well Conductor Casin ❑ Yes ❑ No Depth of Conductor Casing ft bgs Diameter of Conductor Casing inches Well Casing Diameter U inches Total Depth •1111il_It Depth to Water____- It Depth of Casing ft bgs DF.sTR[CT7UN SPF(IFI(7ATION P T AYE, s. Sealing Material from �ft bgs to�ft bgs Filler Material from _ ft bgs to — ft bgs �/e/ Well casing to be perforated by one of the following methods: from ft bgs to ft bgs C'�I'v L�• ❑ Mills Knife Number of cuts every ft and/or D ❑ Explosives❑ Detonating cord ❑ with projectiles every ft ❑ Without projectile OV ❑ Detonating cord and boosters with projectiles every ft ❑ without projectile 18 2020 ❑ Other El Sealing Material Neat Cement(941b bag/5-6 gal water) Sand Ce t sack mix l7 gal water Bentonite Pee Q Bentonite(20%solids) Manufacturer Spec° s % Name L�rL 'f\1)r� Specs on File Specs Submitt RO,P CO(f(V� Placement Method Pumped Free Fal Other C�t1\�s r'1 �cjilAL Seal Completion Complete with Mushroom Cap ft bgs Complete to xisting Surface Pad H DEPT�,. 1 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 REJW1 FOUR IN PECTIONF-: CONTRACTORS SIGNATURE TITLE • • DATE J � '–7—;LV I I 1 I I I DEPARTMENT USE ONLY �G ? Application Accepted By ��1G L Z— Date I I GP�L Area Destruction Inspection By P` '�~� Date 2t`C.l+'• Employee(D## �7 COMMENTS 1 S Y (v. f••C 4P) Y VJ11 e'- S or VUt'jl IS C-4 r Z6 r.?P IQ 1, PC- G - �b , c 0 c 31oi, Z PE SC Received Chec Amount Date Permit/ Invoice# Well ID# Codes Info as Remitted Service Re ues # 73 /C d A EHD 43-08 WELL DESTRUCTION PERMIT 10/5107