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WELL DESTRUCTION PERMIT PUBLIC WATER SYSTEM ❑Yes XNo SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE 3"'FL-STOCKTON CA 95202 - (209)468-3420 NON-REFUNDABLE PERMIT CALL(209)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED rn JOB ADDRESS AVkJ CITY/ZIP � � C R5� I CROSS STREET r�t°_S APN J 7 t1D�3 PARCEL SIZE LAND U E APPLICATION# _ _ I v OWNER 1 S q J 7 tf�f L/([ S �I PHONE J osk le, w 6-- 60 1-/9 f� OWNER ADDRESS _p.U• d CV° Iy r U 5� !� CITY/STATE/ZIP CONTRACTOR / \CO/'/V�QNS� /�/VAY ��51�~'IS PHONE �� (-`9�r' rte q CONTRACTOR ADDRESS �(OzV l/-l one � / r L CITY/STATE/ZIP -fOCl C-57 WELL DRILLING LICENSE NUMBER 6 o 'V EXPIRATION DATE PERFORATION CONTRACTOR PHONE PERF ATION CONTRACTOR ADD S CITY/STATE/ZIP ❑ C- Well Drilling License Number Expiration Date ❑ Burea Alcohol,Tobacco and Fir s-Users of High Explosives License Number Expiration Date ❑ CHP Hazar Material Transportation xplosives License Number Expiration Date ❑ San Joaquin Co Sheriff Coroner Explosive plication and Permit License Number Expiration Date ❑ California Occupatio I Safety Health-Blaster License Number Expiration Date REASON FOR DESTRUCTION ❑ Dry ❑ Replacement Well ❑ Caved In ❑ Pit Well A) Inactive ❑ Test Hole Detected/Suspected Well WaterContaminant(s) Q) C.5i4,5 fky oC/SLvw1 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 ❑ Yes �f-No Depth of Conductor Casing ft bgs Diameter of Conductor Casing inches Well Casing Diameter-& inches Total Depth-y ft Depth to Water ti Depth of Casing ft bgs DESTRUCTION SPECIFICATION Sealing Material from yy ft bgs to O 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 ❑ Mill nife Nu er of cuts every ft and/or ❑ Explosiv ❑ Detonating cord ❑ with prof tiles everyft ❑ wi m�ut projectile Detonating cord and boo ❑ with project every ❑ withoNprojectile ❑ Other Sealing Material ❑ Neat Cement(94/b bag/5-6 ga!water) ❑ Sand Cement sack mix/7 gal water Bentonite Pellets ❑ Bentonite(20%solids) ❑ Manufacturer Spec%solids -- % Name ❑ Specs on File ❑ Specs Submitted Placement Method ❑ Pumped ` C Free Fall 13 Other Seal Completion ❑ CompletewithMushroom Cap -3 ft bgs ❑ Complete to Existing Surface Pad I 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. 1 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. M UM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS CONTRACTORS SIGNATURETITLE �tf/ C[-/' DATE 4�s Or�V K R qyN4 N ®V?5 yF'h'�R ovN ?0?o E' Tye HM,FFou FA,�NT•q�H�Y MFHT DEPARTMENT USE ONLY Application Accepted By I' Date I o7S �CP Area Destruction Inspection By —A c �� _ Date- 6117-a Employee ID# H�� COMMENTS PE SC Received Chec / Amount Date Permit/ Invoice# Well ID# Codes Info By s Remitted Service Request# y369 oC a ►So2 tiS EHD 43-02-008 Well Destruction Permit 1/27/2005