WP0041445 - Laserfiche WebLink

Home Browse Search

* WELL DESTRUCTION PERMIT PUBLIC WATER SYSTEM [:]Yes ❑No L SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPT 1868 East Hazelton Avenue-STOCKTON CA 95205-6232-(209)468-3420 NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS I J S C V CITY21P L o b 1 -I :T 1/ (^ \ l a CROSS STREET K 1 n g A C n FV APN O J J 17 L I 1 PARCEL SIZE_L/A(ND USE APPLICATION# p OWNER r�e.. �GI�j 1� PHONE S IX 09 OWNER ADDRESS J 0`M L \ CITYISTATE/ZIP CONTRACTOR J el\`P y, 1�pp C 1 ,1,11h(( PHONE CONTRACTOR ADDRESS CITY/STATE/ZIP C�S C-57 WELL DRILLING LICENSE NUMBER J`j 1 5�'>7 EXPIRATION DATE 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 )K 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 6 Open Bottom ❑ Gravel Pack ❑ Uncased ❑ Other Well Log copy attached ❑ Yes No Grout Seal ❑ No N/.A ❑ Yes___ft below ground surface(bgs) Hole Diameter _inches Well Conductor Casing 11Yes No Depth of Conductor Casing ft bgs Diameter of Conductor Casing inches Well Casing Diameter G inches Total Depth Uft Depth to Wath �it Depth of Casing it bgs DESTRU(TION SP EC ATION 1 Sealing Material from "q0 ft bgs to ft bgs Filler Material 10.3 SA K from 4 U ft bgs to O ft bgs Well casing to be perforated by one of the following methods: from ft bgs to ft bps ❑ Mills Knife Number of cuts every ft and I or ❑ Explosives❑ Detonating cord ❑ with projectiles every ft ❑ Without projectile ❑ Detonating cord and boosters ❑ with projectiles every It ❑ without projectile ❑ Other Sealing Material Neat Cement(94 to bag/5-6 gal water) Sand Cement 0 sack mix/7 gal water Bentonite Pellets Bentonite(20%solids) Manufacturer Spec%solids % Name Specs on File Specs Submitted Placement Method /1, Pumped Free Fall Other Seal Completion Complete with Mushroom Cap If bgs x 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. MINIMUM/48 HOUR ADVANCE NOTICE REQUIRED FOR INS tP �ECTIONS CONTRACTORS SIGNATURE �yJ—'//�^' � T" �� I�� I�t�I��'DAATE �-J re =Ve1� �C IV �� ivo 10 2fix, aANJ09 HF L- �pN DU/I7Y u r.ob,l e EPq A4 MFNr DEPARTMENT USE ON Y /J / Application Accepted By —�� Date I I . V Area Ll C� Destruction Inspec1fion By Date I 1? 0 Employee ID# COMMENTS v r < C<< PE Sc Received Check#f Amount Date Permit] Invoice# Well ID# Codes InfoB Cash Remitted Service Request# EHD 4308 WELL DESTRUCTION PERMIT revised 4/14/18