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WELL DESTRUCTION PERMIT <br /> PUBLIC WATERSYSfEM❑Y�P"e <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE,3-FL-STOCKTON CA 95202 -(209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL.(209)953-7697 FOR INSPECTIONS EXPIRES L YEAR FROM DATE ISSUED <br /> JOB ADDRESS /,g-3 3i CITYlZIP _ N <br /> CROSS STREET �`.S.,. y►r O PN it O PARCEL SIZE LAND UUSSEE/APPLICATION M V <br /> OWNER _ �/D�r�%1y -- PHONE ) /7 <br /> OWNER ADDRESS ,r�71�' ,L.� dL r��s ✓1 CITY/STATE/ZtP <br /> CONTRACTOR PHONE <br /> CONTRACTOR ADDRESS CITY/STATE/ZIP 95;?YT <br /> p C-57 WELL DRILLING LICENSE NUMBER EXPIRATION DATE--//z?//7e- <br /> PERFORATION <br /> AT£ 7PERRFORATION CONTRACTOR PHONE <br /> PERFORATION CONTRACTOR ADDRESS CITY/STATEMP <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 Contamloent(s) <br /> Adjacent property with contamination(Address) <br /> Known Soil/Water contaminants at adjacent property <br /> EXISTING WEt.L CONSTRUCTION DI;rm s ❑ Open Bottom ❑ Gravel Pack ❑ Untried ❑ Other <br /> Well Log copy attached ❑ Yes ❑ No Grout Seal ❑ No ❑ Yes ft below ground surface(bgs) Hole Diameter incfies <br /> Well Conductor Casing ❑ Yes ❑ No Depth of Conductor Casing B bgs Diameter of Conductor Casing inches <br /> Well Casing Diameter__inches Total Depth LALR Depth to Water_ tt Depth of Caaing ft logs <br /> DESTRUCTION SPECIFICATION <br /> Sealing Material from &16Mft bgs to.�0P R bgs Filler Material from ft bgs to ft bgs <br /> Well casing to be Perforated by one of the following methods: from ft bgs to ft bgs <br /> ❑ MUlt Knife Number of cuts every ft and/or <br /> ❑ Explosives ❑ Detonating cord ❑ with projectiles everyB ❑ without projectile <br /> ❑ Detonating cord and boosters ❑ with projectiles everyR ❑ without projectile <br /> ❑ Other <br /> Sealing Material ❑ Neat Cement(44/h hug/5-6 gal water) V Sand Cement� sack mix 17 gal water ❑ Bemotlite Pellets <br /> ❑ Bentonite(20%solids) ❑ Manufacturer Spw%solids—% Name_ ❑ Specs on File ❑ Specs Submitted <br /> Placement Method❑ Pumped ❑ Free Fall P Otherr•1 r��is f> 7�i ME! <br /> Seal Cot%tletioe ❑ Complete with Mushroom Cap ft bgs ❑ Complete to Existing Surface Pad <br /> 1 HEREBY CERTIFY THAT 1 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. 1 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 /> P�4 DY�AyVCE NOTICE;REQUIRED FORyINSPFcTIONS <br /> CONTRACTORS SIGNATURE ' �DVANCE, TITLE 2I�./,f etAl DATE_-lQ'�A7 <br /> I � I <br /> ,-I <br /> 1 1 {. <br /> I I <br /> L L­----­t--I <br /> DEPARTMENT USE ONLY � <br /> Application Accepted By d,^.,�1°�""�"'�'"'-" r'S,_ Date�L '14Y o Area a le3/� <br /> l <br /> Destruction Inspection By t 11t bL)Ll ,��jyL-Jd� y1 Date 4/'/Z-t10 Employee I DSI AMou. <br /> COMMENTS Te!}10, Yt shoji fl,,s4 6e degirx-Jfir <br /> ;'- 1,7)Lei Ce,e withl'd'>fwye bV0,14 <br /> JU!! <br /> MT1 <br /> PE SC Received 0 heekil/ Amount Date Invoice <br /> Permit/ N R <br /> Codes Info B Remitted Service Re Ojy <br /> 1373 Ufa°!' 1�S` FHr <br /> F.HD 4.1-02-00% w6l tkuractina Perma <br /> 1.272005 <br />