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WELL DESTRUCTION PERMIT <br /> PUBLIC WATER SYSTEM ❑Yes ❑No <br /> SAN JOACUIN 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 I r Q CITY/ZIP <br /> CROSS STREET 144 APN !2 `L 9 ©3O y % PARCEL SIZE r 5'LAAND USE APPLICATION# a <br /> OWNER /I PHONE 93 p 3 3 3 6 <br /> OWNER ADDRESS CITY/STATE/ZIP Z7.SC AflD/t C A 5--? O <br /> CONTRACTOR(2&/,o> t2 GC• / Cpsn PHONE (, 6 y/ n) q 3/2 <br /> CONTRACTOR ADDRESS O t R 0 CITY/STATE/ZIP <br /> 6/ C-57 WELL DRILLING LICENSE NUMBER Y 2 I EXPIRATION DATE <br /> PERFORATION CONTRACTOR PHONE <br /> PERFORTION CONTRACTOR ADDRESS CITY/STATE/ZIP p <br /> El'--C-57 Well Drilling License Number �3 % O 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 Nu er xpiration Date <br /> REASON FOR DESTRUCTION ❑ Dry ETReplacement Well ❑ Caved In 0 ft II I nacl ive ff" fs ILole <br /> Detected/Suspected Well Water Contaminant(s) <br /> Adjacent property with contamination(Address) Farm, it m <br /> Known Soil/Water contaminants at adjacent property • being eornpletedA <br /> ,� � _,I„r or � <br /> EXISTING WELL CONSTRUCTION DETAILS ❑ Open Bottom Y�hravel Pack Un pada h airs IVIS or! <br /> Well Log copy attached ❑ Yes 13-'No Grout Seal ❑ No ❑ Yes ft below ground surface(bgs) Hole Diameter inches <br /> Well Conductor Casing 11 Yes ❑ No Depth of Conductor Casing ft bgs Diameter of Conductor Casing inches <br /> Well Casing Diameter inches Total Depth ft ft Depth to Water �/'5— ft Depth of Casing ft bgs <br /> DESTRUCTION SPECIFICATION <br /> Sealing Material from��ft bgs to ft bgs Filler Material from ft bgs to 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 /> Sealing Material _ Neat Cement(94 Ib bag/5-6 gal water) Sand Cement sack mixll gal water - Bentonite Pellets <br /> Bentonite(20%so' s) - Manufacturer Spec%solids % Name Specs on File Specs Submitted <br /> Placement Method 0 Pumped ❑ Free Fall Other <br /> Seal Completion Complete 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 /> 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 /> tr_21_ <br /> UR ADV CE NOTICE REQUIRED FOR INSPECNS (� �j <br /> CONTRACTORS SIGNATURE TITLE �� 7 f 7 DATE / 'A / r <br /> V _n <br /> C7 <br /> e I= cn <br /> -I.- W- <br /> ECPI�JO .o <br /> •�,,� <br /> 2014 X w <br /> �,c�ulN cour��' <br /> SAN {� o <br /> LNVVIAOMENTAL <br /> `� tiEAl:l H t)EPARTMENT �� A V E: <br /> cty <br /> E <br /> Eie <br /> r' � <br /> DEPARTMENT USE ONLY <br /> Application Accepted By_ Date L 4— Area CA 6 a <br /> Destruction Inspection By Date Employee ID#_ <br /> COMMENTS t 1;,,fp,pl <br /> PE SC Received / Amount ate Permit/ Invoice# Well ID# <br /> Codes Info B Cash Remitted / Service/rRequest# <br /> ii A -• 1 �' ! r V� V <br /> EHD 43-03 WELL DESTRUCTION PERMIT <br /> 10/5/07 <br />