Laserfiche WebLink
WELL DESTRUCTION PERMIT <br /> PUBLIC WATER SYSTEM ❑Yes O�No <br /> SAN JOAOJIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 600 E MAIN STREET-STOCKTON CA 95202 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS ) pr C, l CIN/ZIP r� .%d i ✓.E'='1_- m <br /> CROSS STREET L tom-`_ �PNC19 / L )—(r)Sf PARCEL SIZE" YLAND USE APPLICATION# v <br /> _ v <br /> OWNER 46ti e_i PHONEf • J�� �f�'/ <br /> OWNER ADDRESS CITY/STATE/ZIP /�y'L,(6 i�tom. (_-Ci .1' ��- <br /> CONTRACTOR �1.''l )Lr�II �%�+��5 //Y���� t" Y PHONE _.�/�J���� <br /> CONTRACTOR ADDRESS / 1 / (3� /"S /� F�// p� CITY/STATE/ZIP zlz off, L <br /> )a—C-57 WELL DRILLING LICENSE NUMBER ({ (G'3�'L Z- EXPIRATION DATE <br /> PERFORATION CONTRACTOR PHONE <br /> PERFORATION CONTRACTOR ADDRESS CITY/STATE/ZIP <br /> ❑ -57 Well Drilling License Number Expiration Date <br /> ❑ Bureau of Alcohol,Tobacco and Firear s feR Ex iration Date <br /> ❑ CHP Hazardous Material Transportatio i orI%IpTve <br /> E' [ie1ftED7- <br /> • <br /> Expiration Date <br /> San Joaquin County Sheriff-Coroner Explosives Application and Permit Li nse, utmlab,�}r Expiration Date <br /> ❑ California Occupational Safety Health-Blaste?rMit mays have exprL nv F�11�r Expiration Date <br /> REASON FOR DESTRUCTION ❑ Dry ❑ A6� p geeo !t ell ❑ Inactive ❑ Test Hole <br /> Detected/Suspected Well Water Contaminant(s) ,`, ,,imnmenta1 L.l8;41sDvi lop <br /> Adjacent property with contamination(Address) <br /> Known Soil/Water contaminants at adjacent property <br /> EXISTING WELL CONSTRUCTION DETAILS tbf—Open Bottom ❑ Gravel Pack ❑ Uncased ❑ Other <br /> Well Log copy attached ❑ Yes >�'No Grout Seal ❑ No ❑ Yes ft below ground surface(bgs) Hole Diameter inches <br /> Well Conductor Casing ❑ Yes ❑ No Depth of Conductor Casing ft bgs Diameter of Conductor Casing inches <br /> Well Casing Diameter_ inches Total Depth ft Depth to Water ft Depth of Casing ft bgs <br /> DESTRUCTION SPECIFICATION <br /> Sealing Material from i; ft bgs to ft bgs Filler Material {fit-r from I >v ft bgs to r =1 ft bgs <br /> Well casing to be perforated by one of the following methods: from ft bgs to ft bgs <br /> ❑ Mills Knife Number of cuts every ft and/or <br /> ❑ Explosives ❑ Detonating cord ❑ with projectiles everyft ❑ without projectile <br /> ❑ Detonating cord and boosters ❑ with projectiles everyft ❑ without projectile <br /> ❑ Other <br /> Seal irg Material C Neat Cement(94 lb bag/5-6 gal water) Sand Cement sack mixll gal water Bentonite Pellets <br /> Bentonite(20%solids) Manufacturer Spec%solids % Name ❑ Specs on File Specs Submitted <br /> Placement Method 1- Pumped ❑ Free Fall - Other <br /> Seal Completion AComplete with Mushroom Cap ft bgs - 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 /> JOAQUIIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I 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 /> MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR ItJSP/ECTIONS <br /> CONTRACTORS SIGNATURE` C ��G��G��� TITLE � DATE <br /> q 1 <br /> 41 a <br /> Y ENT <br /> Az <br /> OCT 0 8 2013 <br /> SAN JOAQUIpli COiiNTlr <br /> ENVIR010ENTAL <br /> I <br /> HEALTH DEPARTMENT <br /> DEPARTMENT USE ONLY ) <br /> Application Accepted By Date rti l Area k_// j <br /> Destruction Inspection By Date Employee ID#_ <br /> COMMENTS t w wiJit ty (>� ti S(klLl L� ail C-Gi��7 5r L Z A TI <br /> PE SC ReceivedCheck#/ Amount D to Permit/ Invoice# Well ID# <br /> Codes Info B ash Remitted Service Request# <br /> EHD 43-08 WELL DESTRUCTION PERMIT <br /> 10/5/07 <br />