WP0041299 - Laserfiche WebLink

Home Browse Search

WELL DESTRUCTION PERMIT PUBLIC WATER SYSTEM ❑Yes ❑No SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 East Hazelton Avenue-STOCKTON CA 95205 - (209)468-3420 NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS ��OOOOO��...EXPIIR��ES 1 YEAR AlOM DATE ISSUED JOB ADDRESS �� % �• OSTE CITY/ZIP x&49 .9 J 3 0l -�Q .2- z.. _/ t7 CROSSSTREET OV 4 Mk4fi ,��,6�APN�,:;$5 .�8�' �� PARCEL SIZtI64 LAND USE APPLICATION# d OWNER_�i/4W JQvS+F LJt:Ir+ �GLCJRf• �GffL1lL �J ST PHONE In v.. OWNER ADDRESS .5411_�A CITY/STATE/ZIP�/ B CONTRACTOR e4N_4 "OL � J SNS �C� PHON f/ .S 3 ��®fA �,�9 p CONTRACTOR ADDRESS_®g3bf GveSF�4 GT yw CITY/STATE/ZIP LipVw6Y Apf + fS_:?7D C-57 WELL DRILLING LICENSE NUMBER EXPIRATIPN DATE-7s t •4;c %/ IF ZPERFORATION CONTRACTOR PHONE PERFORATION CONTRACTOR ADDRESS CITY/STATE/ZIP ❑ C-57 Well Drilling License Number 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 Safety Health-Blaster License Number Expiration Date REASON FOR DESTRUCTION ❑ Dry K Replacement Well ❑ Caved In ❑ Pit Well ❑ Inactive ❑ Test Hole Detected/Suspected Well Water Contaminant(s) 11/O/Ve, Adjacent property with contamination(Address) Noyes Known Soil/Water contaminants at adjacent propertyL(/(J�/� 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 Casing ❑ Yes ❑ No Depth of Conductor Casing ft bgs Diameter of Conductor Casing inches Well Casing Diameter inches Total Depth —ft Depth to Water it Depth of Casing ft bgs DESTRUCTION SPECIFICATION Sealing Material from �� ft bgs to si ft bgs Filler Material from ft bgs to ft bgs . Well casing to be perforated by one of the following methods: from it bgs to ft bgs ❑ Mills Knife Number of cuts every ft and/or ❑ Explosives ❑ Detonating cord ❑ with projectiles every ft ❑ without projectile ❑ Detating cord a�}d bb000ster wi projectiles every _ft ❑ without projectile ImOther� 67,61,�647— �lP�/ 7 X'� ��, jeee_e -/VQ Sealing Material n Neat Cemend(94/b bag/5-6 gal water)[*/Sand Cement sack mixl7 gal water ❑ Bentonite Pellets ❑ Bentonite(20%dsolids) ❑ Manufacturer Spec%solids % Name ❑ Specs on File ❑ Specs Submitted Placement Method 'HCl Pumped P"Free Fall 71 Other Seal Completion' 11✓Complete with Mushroom Cap ft 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 REGULATION$. 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 COMPENSATIOWLAWS. I,NIUMHOUR ADVANCE NOTICE REQUIRED F R INSPECTIONS CONTRACTORS SIGNATURE ' TITLE DATE t• -- - - _...... ............ ... _�---�. - -- --- -- - -2--- - Y I - l DEPARTMENT USE ONLY j �J Application Accepted By L _ Date �/8 D�. a Area Destruction Inspection qqBy p Date V ] ZD Employee ID# Ar' r COMMENT 11 {145 bPeVt ,>!c'sdYa C -57 i1b� dvf' PIT !Yt }rUl k7 '5 T' VJe, �e .I PE Sc Received Check#/ Amount Permit/ Codes Info B Cash Remitted bate Service Request# Invoice# Well ID# 4374 ►�s 3a Z•?.� �2 EHD 43-08 n (� c_ WELL DESTRUCTION PERMIT 4/30/12