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WELL DESTRUCTION PERMIT PUBLIC WATER SYSTEM ❑Yes KN. SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPT 1868 East HaZel n Avenue-STOCKTON CA 95205-6232 -(209)468-3420 NON-REFUNDABLE PERMIT CALL 209 3-7697 FOR INSPECT O EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESSUPRll l ISI b ZP t Cw �1• S 40 CROSS STREET r y, LSN PN 16 O C) PARCEL SIZF7 D USE APPLI TION# p OWNER /1(Of< ^ i` f PHONE OWNER ADDRESS OI✓ DolusqlvJ O CITYISTATEE/ZIP CONTRACTOR Q I I N PHONE X CONTRACTOR ADDRESS 77V 41,5VIdeotCITYISTATE/ZIP n Z, C57 WELL DRILLING LIICsEN E NUMBER I EXPIRATION DATE �j PERFORATION CONTRACTOR CA Be, p PHONE G23— / S' OjRq _2 PERFORATION CONTRACTOR ADDRESS 77x.3 G ��1 �411G CITY/STATE/ZIP p,O/'lII `" �Q C-57 Well Drilling License Number 110 Expiration Dater 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 ❑ Replacement Well ell ❑ Caved In ❑ Pit Well Inactive C1 Test Hole Detected/Suspected Well Water Contaminant's) '�V Adjacent property with contamination(Address) Known Soil/Water contaminants at adjacent property AY A ExISTING WELL CONSTRUCTION DETAILS / Open Bottom ❑ Gravel Pack 161Uncased ❑ Other Well Log copy attached ❑ Yes No Grout Seal ❑ No ❑ Yes _ft below ground surface(bgs) Hole Diameter inches Well Conductor Casing❑ YBS ❑ No Depth of Conductor Casing ft bgs ` Diameter of Conductor Casing I inches Well Casing Diameter _inches Total Depth ft Depth to Waterab.,�7 ft Depth of Casing fl bgs DESTRt Q ION SPECIFIC IA]ION / Sealing Material from I MilZ—ft bgs to ft bgs Filler Material - _ from ft bgs to ft bgs Well casing to be perfoolecl by one of the followingth s: from ft bgs to _ft bgs Mills Knife Number of cuts every_), ft and/or ❑ Explosives❑ Detonating cord ❑ with projectiles every ft ❑ without projectile ❑ Detonating cord and boosters ❑ vnth projectiles every `f ❑ without projectile ❑ Other Sealing Material Neat Cement(94/b bag/5-6 gal water) Sand Cement A sack mix/7 gal water Bentonite Pellets Bentonite(20%solids) ufacturer Spec%solids_% Name Specs on File Specs Submitted Placement Method Pumped Free FII Other Seal Completion Complete vn shroom 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 REGULATIONS. 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 COMPENSATION LAWS. ///n/'��7INIIMOUM 48 OUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS ^[ n CONTRACTORS SIGNATURE Y 6 TITLE / , (.�/ /rl I7DATE v'y/O—D�V �t F �MFN � F cE/VES SqN B ?y ?4?0 F � Q��N u �AA N ,PgRT � /V � b S MFNT E ARTMENT USE ONLY vq Application Accepted By Date Area r Destruction Inspection By Date L V^ Employee ID# COMMENTS k r, n J (. 1 1 1V C • Cu01 (CLIA Yl 5 I) CA w r ex ti Cr c u t 1 e !- h m PE SC Received C_h-_ Amount Date Permit/ Invoice# Well ID# Codes Into f Cash Remitted Service Request# fJ' i�< EHD 43-08 WELL DESTRUCTION PERMIT revised 4/14/18