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r <br /> WELL DESTRUCTION PERMIT <br /> PUBLIC WATER SYSTEM ❑Yes ❑No <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPT 1868 East Hazelton Avenue-STOCKTON CA 95205.6232-(209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS q EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS �JS,b Z.40/1­v T 9d. CITYIZip l- D <br /> CROSS ST�RE/E/T �'S 61 LIC fy dAPN I007•31D" 3/ PARCEL SIZE LAND USE APPLICATION# b <br /> OWNER rl AI /Y'IL )7 k Y �j PHON1a4191) 3pal-PS741 Q r <br /> OWNER ADDRESS G 977 /E/�"f r O��'����! F� CITY/STATE/ZIP,/YYi7T��//v� • / <br /> /� �—' / <br /> CONTRACTOR CAW DAL/: AJS INC. �s� PHONE Z—JyL�3 l� <br /> CONTRACTOR ADDRESS �T 3�� W/GS T14- �v/ �,Q, CRYISTATE/ZIP' /V,9 44. 70 <br /> J(C-57 WELL DRILLING LICENSE NUMBER s r 7 EXPIRATION DATE 7 Z J <br /> PERFORATION CONTRACTOR f PHONE <br /> PERFORATION CONTRACTOR ADDRESS CITYISTATE/ZIP <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 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 bgs Diameter of Conductor Casing Inches <br /> Well Casing Diameter inches Total Depth ft Depth to Water ft Depth of Casing It bgs <br /> DESTRCCTSON SPECIFICATION A,q <br /> Sealing Material from ft bgs to It bgs Filler Material from ft bgs to ft bgs RF 1 'AIS/A <br /> Well casing to be perforated by one of the following methods: from It bgs to ft bgs r C�i F/V;�. <br /> ❑ Mills Knife Number of cuts every ft and/or 14 <br /> ❑ Explosives❑ Detonating cord ❑ with projectiles every It ❑ Without projectile �/ <br /> Sq *0/��� �O <br /> ❑ Detonating cord and boosters [I with projectiles every ft ❑ without projectile 11 Other <br /> Sealing Material Neat Cement(94 1b bag/5-6 gal water) Sand Cement sack mix/7 gal water Bentonite Q�/ O?O <br /> Bentonite(20%solids) Manufacturer Spec%solids_% Name Specs on File Specs Subml <br /> Placement Method Pumped Free Fall Other H pF�tiJ�CO N <br /> Seal Completion Complete with Mushroom Cap ft bgs Complete to Existing Surface Pad Ty <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 MWS. <br /> MI U 4 OUR ADVANC NOTICE REQUIREDF R INSPECTIONS �I <br /> CONTRACTORS SIGNATURE TITLE <br /> ,(r 110'e- rl- DATE II • ZD2AV <br /> I i I l i I I I 1 i l i t <br /> : 1 <br /> J DEPARTMENT USE ONY <br /> Application Accepted By �_ 1� Date I 1 AoJs Area 7 <br /> Destruction InspectionI ByQ1kJdy_ Date Employee ID# DA 0 <br /> COMMENTS ueli i J y", e Ji' "e g <br /> pjtbe • <br /> N <br /> PE SC Received Check#/ Amount Permit! <br /> Codes Info Cash Remitted —I rvice Request# Invoice# Well ID# <br /> EHD 43-08 /n/�-,. /� WELL DESTRUCTION PERMIT <br /> revised4/14/18 / /1 Y /` / 2-733 <br />