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WELL DESTRUCTION PERMIT <br /> PUBLIC WATER SYSTEM ❑Yes ❑No <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 600 E MAIN STREET-STOCKTON CA 95202 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL(209)953-76U FOR INSPECTIONS EXPIREpSy I YEAR FROM DATE ISSUED <br /> JOB ADDRESS l 9 S 3 S c R o L ? o n CITY/ZIP / J [v b <br /> / m <br /> CROSS STREET L lv APN 2 '/s 13 d y 3 PARCEL SIZE3,1 LAND USE APPLICATION# O <br /> OWNER K 0J` PHONE 2,o 9 s g 1-7 21 <br /> OWNER ADDRESS n / OL CITY/STATE/ZIP �C ®i► l_/t g r-3 G6 y <br /> CONTRACTOR C4 �} 2 � (� -r!Jkl C PHONE 9/D9 G-,3 2 <br /> / 'Q -rt'ADDRESS <br /> hd/ C-57 WELL DRILLING LICENSE NUMBER Of EXPIRATION DATE—J-- <br /> -3 � S <br /> PERFORATION CONTRACTOR PHONE <br /> PERFORATION CONTRACTOR ADDRESS CITY/STATE/ZIP r <br /> C9� C-57 Well Drilling License Number !!�3 ct `Z l 8 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 N4Ther Expiration Date <br /> ❑ San Joaquin County Sheriff-Coroner Explosives Application and Permit License Nuc ibw xpiration Date <br /> ❑ California Occupational Safety Health-Blaster License Number xpiration Date <br /> REASON FOR DESTRUCTION 1 .Dry replacement Well ❑ Caved In ❑ c it may H �bli� Oji;; 1 T76tHole <br /> Detected/Suspected Well Water Contaminant(s) r + <br /> Adjacent property with contamination(Address) <br /> Known Soil/Water contaminants at adjacent property -/ <br /> EXISTING WELL CONSTRUCTION DETAILS ❑ Open Bottom Id Gravel Pack ❑ Uncased ❑ Other <br /> Well Log copy attached Qhs 9-1-'No Grout Seal ❑ No Q'Yes ft below ground surface(bgs) Hole Diameter 2 yY inches <br /> Well Conductor Casing ❑ Yes C3 No Depth of Conductor CasingAte ft bgs Diameter of Conductor Casing Ik 0' inches <br /> Well Casing Diameter (� � inches Total Depth (n 66 ft Depth to Water �ft Depth of Casing (Z ft bgs <br /> DESTRUCTION SPECIFICATION nn '' 1 p <br /> Sealing Material from ft bgs to ft bgs Filler Material k oa t,1.9 e_ +U Q- from ft bgs to GQvkbt' 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 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) Sand Cement sack mix17 gal water Bentonite Pellets <br /> Bentonite(20%solids) Manufacturer Spec%solids % Name +y440btn Specs on File : Specs Submitted <br /> Placement Method k"- Pumped Free Fall Other <br /> Seal Completion _ Complete with Mushroom Cap /�. ft bgs omplete 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 COMPENSATIO LAWS. <br /> INIM 24R ADVANCE NOTICE REQUIRED FOR INSP CT ONS <br /> CONTRACTORS SIGNATURE TITLE W�Y DATE I <br /> PAYWIE <br /> tcEl <br /> �.. <br /> ° AN IA Ifit cq�tiTY - - <br /> L VL. �RTMENT <br /> DEPARTMENT USE ON Y <br /> D <br /> Applicadon Accepted By- -�- Y L ate <br /> Z r Area <br /> Destruction Inspection By l Date Employee ID#_ <br /> COMMENTS (- li»t-4t j:,t �`�-i.��% ILJ��L• 1 I� rVf <br /> PE SC Received Check#/ Amount Date Permit/ Invoice# Well ID# <br /> Codes Info By Cash Remitteo Service Request# <br /> EHD 43-08 WELL DESTRUCTION PERMIT <br /> 10/5/07 <br />