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WELL DESTPUCTION PERMIT PUBLIC WATER SYSTEM ❑Yes ❑No SAN JOAGUIN 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 2 " c w w � t 1� CITY/ZIP_��11i�'r Ct 1C�Cis Y t�LI� ^� �y R CROSS STREET 0aN4,7 n e- APIN �1 oa PARCEL SIZE I'd !?LAND USE APPLICATION# � OWNER F✓ti olce S klA rWfF rclG fr PHONE ('_ J j f OWNER ADDRESS 1(,7 / DpyriPS (``rd ,/� CITY/STATE/ZIP Y-ii CONTRACTOR)`,Go IA 6roSS (�Jells T PHONE 7� 3120 N CONTRACTOR ADDRESS 14. • V3 6 J CITY/STATE/ZIP L.-,4, 1T IJ,S 2 y/ C-57 WELL DRILLING LICENSE NUMBER '-�6 61-2 EXPIRATION DATE--14-6 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=0R DESTRUCTION Dry ❑ Replacement Well ❑ Caved In ❑ Pit Well ❑ Inactive ❑ Test Hole Detected/Suspected Well Water Contaminants) 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 It below ground surface(bgs) Hole Diameter _ - - inches Well Conductor Casing ❑ Yes ❑ No Depth of Conductor Casing ft bgs Diameter of Conductor Casing inches Well Casing Diameter_inches Total Depth __'LZ It Depth to Water 2 It Depth of Casing _It bgs DESTRUCTION SPECIFICATION Sealing Material from 0 ft bgs to _ � ft bgs Filler Material + ..��c— from ft bgs to It bgs Well casing to be perforated by one of the following methods: _ from It bgs to ft bgs ❑ Mills Knife Number of cuts every _._ ft and/or ❑ Explosives ❑ Detonating cord ❑ with projectiles every It ❑ without projectile ❑ Detonating cord and boosters ❑ with projectiles every ft ❑ without projectile ❑ Other__ Sealing Material Neat Cement(94 lb bag/5-6 gal water) Sand Cement sack mix%/gal water Bentonite Pellets Bentonite(20%solids) Manufacturer Spec%solids_._ o Name Specs on File Specs Submitted Placement Method Pumped Free Fall Other Seal Completion Complete with Mushroom Cap 3_ 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. tis II!r UM HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS SCONTRACTORS SIGNATURE ' TITLE NPp/q DATE I Z— J— _ . . _. __ __..a.._.. ._... .. _ _._. I I , j.. I................... It _.... ......._....._ , I _ 2 020 >:l I SAN JOA Ell QUIN COU _-. _ _ ...--....... H ME EgL SEP--a— T Y _1 DEPARTMENT USE ONLY y Application Accepted By _ Date /v�J/71-I'll 1 Area Destruction Inspection By _ Date Zc7 Employee ID# COMMENTS PE Sc Received Check#/ Amount Date Permit/ Invoice# Well ID# Codes Info B Cash Remitted service Request# EHD 43-08 WELL DESTRUCTION PERMIT 4/30/12