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WELL DESTRUCTION PERMIT PUBLIC WATER SYSTEM [:1 Yes fo SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE 3M'FL-STOCKTON CA 95202 - (2099)468-3420 NON-REFUNDABLE PERMIT CALL(20,9,")953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED 41 JOB ADDRESS /I /Ja7 dd/1 fcr / CITY/ZIP CROSAWA APN 07 9 a o I PARCEL SIZE I LA D UUSSEyA�PPLICATION# OWNER PHONE �J �� `�GiIG/ y to OWNER ADDRESS Y CITY/STATE/ZIP 4-------- � CONTRACTOR !rG"/� HONE tF/ J2!;�p r CONTRACTOR ADDRESS CITY/STATE/ZIP 9.�zf C-57 WELL DRILLING LICENSE NUMBER f /hr (� EXPIRATION DATE 2 PERFORATION 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 ❑ Replacement Well ❑ Caved In ❑ Pit Well Inactive ❑ Test Hole Detected/Suspected Well Water Contaminant(s) Adjacent property with contamination (Address) Known Soil/Water contaminants at adjacent property 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 ❑ Ye1.0'q /ss ❑ No Depth of Conductor Casing ft bgs Diameter of Conductor Casing inches Well Casing Diameter /I K inches Total Depth ^7,9 ft Depth to Water_ _7S ft Depth of Casing ft bgs DESTRUCTION SPECIFICATION Sealing'Material from 0 ft bgs to ft bgs Filler Material from ft bgs to ft bgs Well casing to be perforated by one of the following methods: 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 13with projectiles every ft ❑ without projectile ❑ Other 3�� Sealing Material ❑ Neat Cement(94/b hag/5-6 gal wafer) ❑ Sand Cement .sack mix/7 gal water �Bentonite Pellets ❑ Bentonite(20%solids) ❑ Manufacturer Spec%solids % Name ❑ Specs on File ❑ Specs Submitted Placement Method 0 Pumped ❑ Free Fall ❑ Other a `�� 65� Seal Completion ❑ Complete with Mushroom Cap ft bgs Complete to Existing Surf a Pad 1 HEREBY CERTIFY THAT 1 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 1 AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION LAWS. MI I 4 U A E NOTICE REQUIRED FOR INSPECTIONS CONTRACTORS SIGNATURE TITLE / �� DATE PA'YiWENT RECE►VE® 0 2020 SAN JOAQUIN COUNTY EWRONMENTAL HEALTH DEPA LX DEPARTMENT USE ONLY Application Accepted By Date 1,R e�OaG6Area `7h Destruction Inspection By 1<TH.��, 1, i�ior�t t L`e-ti L Date (7_11FJ2 9Zz Employee ISD/# PA COMMENTS .L pnL'ch L I uLl/G k4a-fer �WM Y S � z QY1(� pot Alae to e1��N/ int�ys►vn t{ sofrgtP .4,.1 4.. PE SC Received (CheeW Amount Date Permit/ Invoice# Well ID# Codes Info By Cash Remitted Service Request Al X1373 I a Z . Ids IZ IL �•LPp�ItSDI EHD 43-02.008 Well Destruction Permit 1/27/2005