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WELL DESTRUCTION PERMIT <br /> PUBLIC WATER SYSTEM ❑Yes0 <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 East Hazelton Avenue-STOCKTON CA 95205 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> l, 7S �-r]�47 CITY/ZIP <br /> JOB ADDRESS_ >er ? <br /> CROSS STREET �'�/ 'C' �7 0�J Jp PARCEL SIZE LAND USE APPLICATION# <br /> OWNER �y PHONE <br /> OWNER ADDRESS CITY/STATE/ZIP <br /> CONTRACTOR —PHONE <br /> CONTRACTOR ADDRESS L��� / J / CITY/STATE/ZIP <br /> ❑ C-57 WELL DRILLING LICENSE NUMBER ILI''�J�C EXPIRATION DATE <br /> PERFORATION CONTRACTOR PHONE <br /> PERFORATION CONTRACTOR ADDRESS CITY/STATE/ZIP <br /> ❑ C-57 Well Drilling License Number Expr <br /> ,,,lion Date <br /> ,, '„r <br /> 11 Bureau of Alcohol,Tobacco and Firearms-Users of High Explosives License Number Expiration 6�e 2120 <br /> ❑ CHP Hazardous Material Transportation for Explosives License Number S'-(pl(M"ate <br /> ❑ San Joaquin County Sheriff-Coroner Explosives Application and Permit License Number N .F� OTAjOlr�� <br /> H <br /> ❑ California Occupational Safety Health-Blaster License Number Expirafidrl bad¢ <br /> REASON IFOR DESTRUCTION ❑ Dry ❑ Replacement Well ❑ Caved In ❑ Pit Well Inactive ❑ Test Hole <br /> Detected/Suspected Well Water Contaminant(s) <br /> Adjacent property with contamination(Address) <br /> Known Soil/Water contaminants at adjacent property ____ <br /> EXISTING WELL CONSTRUCTION DETAILS ❑ Open Bottom ❑ Gravel Pack ❑ Uncased ❑ Other <br /> Well Log copy attached ❑ Yes ❑ No Grout Seal ❑ No ❑ Yes It below ground surface(bgs) Hole Diameter inches <br /> Well Conductor Casing ❑ Yes ❑ No Depth of Conductor Casing ft b s Diameter of Conductor Casing inches <br /> Well Casing Diameter_____ l_inches Total Depth _��_� ft Depth to Water_ _ �' ��t Depth of Casing It bgs <br /> DESTRUCTION SPECIFICATION <br /> Sealing Material from ___ft bgs to _''r!_ ft bgs Filler Material _ from _ __ ft bgs to ft bgs <br /> Well casing to be perforated by one of the following methods: from __It bgs to It bgs <br /> ❑ Mills Knife Number of cuts every ft and/or <br /> ❑ Explosives ❑ Detonating cord ❑ with projectiles every ft ❑ without projectile <br /> ❑ Detonating cord and boosters ❑ with projectiles every ft ❑ without projectile <br /> ❑ Other <br /> Sealing Material Neat Cement(94 Ib bag/5-6 gal water)A. Sand Cement /Ll: > <br /> sack mixll gal water Bentonite Pellets <br /> Bentonite(20%solids) Manufacturer Spec%solids % Name ❑ Specs on File Secs Submitted <br /> Placement Method Li Pumped L Free.FalJ - Y Other � � rrz�fZ7/ <br /> Seal Completion Complete with Mushroom Cap j� J� it 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 /> JOAQUIN 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 /> DVANCE NOTICE REQUIRED FOR INSPECTIONS <br /> L' <br /> CONTRACTORS SIGNATURE / ' 1�1I��ylly� TITLE // � C DATE <br /> .. -- {-- -- - - - .. <br /> /tea - -- - _ _... �-# <br /> I � <br /> -- ---.. _. . .. <br /> .................. ......- ....._.. ................. ... <br /> i <br /> H-- <br /> DEPARTMENT USE ONLY I <br /> Application Accepted By _7 Z_�� Date III��y�0 Area /C�`/ <br /> DestructionInspection By Date lEmployee ID# <br /> COMMENTS t;l ` �+�K W e�� leAl"!ns -(D, SROo:JJ3S <br /> PE SC Received (ChecUP Amount Date Permit/ Invoice# Well ID# <br /> Codes Info B Remitted Service Request# <br /> L)3­7s ic- i 1'4 <br /> EHD 43-08 WELL DESTRUCTION PERMIT <br /> 4/30/12 <br />