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WELL DESTRUCTION PERMIT PUBLIC WATER SYSTEM ❑Yes ❑No SAN JOAOUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 East Hazelton Avenue-STOCKTON CA 95205 - (209)468-3420 NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS CITY/ZIP CROSS ST EET I I W� APN f ` �l ` y FI ( PARCEL SIZE LAND USE APPLICATION# OWNER ISI 'r PHONE UO(i L (✓ ' /16- J� OWNER ADDRESS I[JI /�NOW4 CITY/STATE/ZIP 2 �7 D CONTRACTOR 124) WII / v PHONE q3 l-1 CONTRACTOR ADDRESS 6 & &J p�/ CITY/STATE/ZIP �(/f l C-57 WELL DRILLING LICENSE NUMBER O u, EXPIRATION DATE PERFORATION CONTRACTOR PHONE PERFORATION CONTRACTOR ADDRESS CITY/STATE/ZIP ❑ C-57 Well Drilling License Number Expiration Date ❑ Bureau of Alcohol,Tobacco and Fir rms-Users of High Explosives License Number Expiration Date I-] CHPHazardous Material Transportatio or 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 roperty _EXISTING WELL CONSTRUCTION DETAILS ❑ Open Bottom ❑ Gravel Pack ❑ Uncased ❑ Other _ Well Lag copy attached ❑ Yes No Grout Seal ❑ No ❑ Yes __It below ground surface(bgs) Hole Diameter inches Well Conductor Casing ❑�y Yes No Depth of Conductor Casing ft bgs Diameter of Conductor Casing _ inches Well Casing Diameter b_ inches Total Depth _Q_ft Depth to Water ft Depth of Casing It bgs DESTRUCTION SPECIFICATION Sealing Material from _ 0 _ff bgs to It bgs Filler Material from ft bgs to ft bgs Well casing to be perforated by one 8f the following metho : _ __ - _ from_�ft bgs to _ _ ft bgs ❑ !Mills Knife `_, Number;of cuts every ft and/or. ❑ iExplosives ❑ De'lh ating cord ❑ with X ctiles every ft ❑ without projectile ❑ Detonating cord and bo sters ❑ with tiles every _ _ft ❑ witho6tprojectile ❑ Other Sealing Material Neat Cement(94 Ib bag/5-6 gal water) Sand Cement sack mixll gal water /� Bentonite Pellets Bentonite(20%solids) Manufacturer Spec%solids_ Name —' _ Specs on File Specs Submitted Placement Method Pumped Free Fa� Other Seal Completion Complete with Mushroom 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. 4e INIMUM 7OUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS CONTRACTORS SIGNATURE (710TITLE DATE V ........... ......... ............*__ ........... ..... _._..._..._. _...... .. ... ......... - ............ - - i IV i . NOV - ..__ ._._...__._._. ._.._.._......_................... ' ... FJ /AoN/N ` I , . STH oEayR DEPARTMENT USE ONLY Application Accepted By_ Q� zDate It as� is.020 Area A`^/ Destruction Inspection By 1C Date l ZI m I� Employee IN COMMENTS PE SC Received Amount ate Permit/ Invoice# Well ID# Codes Info B as Remitted Service Request# EHD 43-08 WELL DESTRUCTION PERMIT 4/30/12