WP0041241 - Laserfiche WebLink

Home Browse Search

WELL DESTRUCTION PERMIT PUBLIC WATER SYSTEM ❑Yes [:]No SAN JOAQUIN 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 n� r JOB ADDRESS Z I Z S L&4A.1Ay /w` CITY/ZIP Y CROSS STREET_L.e V _APN OY&V l PARCEL SIZE LAND USE APPLICATION# z OWNER PHONE r n OWNER ADDRESS CITY/STATE/ZIP CONTRACTOR - �o (� PHONE CONTRACTOR ADDRESS Po•° • �. ,� (6 CITY/STATE/ZIP L e� A CJS Z Y I 16- C-57 WELL DRILLING LICENSE NUMBERrn`tin l L 3 EXPIRATION DATE-26 ta- PERFORATION CONTRACTOR PHONE 327-3 t ZQ 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 ❑ Replacement Well ❑ Caved In ❑ Pit Well ilk[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 Log copy attached ❑ Yes ❑ No Grout Seal ❑ No ❑ Yes - --__ ft 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 __J inches Total Depth 40 It Depth to Water _ It Depth of Casing it bgs DESTRUCTION SPECIFICATION Sealing Material from It bgs to le It bys Filler Material from ft bgs to It bgs Well casing to be perforated by one of the following methods: from ft bgs to _ ft bgs ❑ Mills Knife Number of cuts every_____ ._ ft and/or_ ❑ Explosives ❑ Detonating cord ❑ with projectiles every _ ft ❑ without projectile ❑ Detonating cord and boosters ❑ with projectiles every ft ❑ without projectile ❑ Other_ Sealing Material Neat Cement(94 lb bag/5-6 gal water) I Sand Cement sack mix17 gal water Bentonite Pellets K Bentonite(20%solids) Manufacturer Spec%solids—% Name _ Specs on File Specs Submitted Placement Method Pumped A_ Free Fall Oth Seal Completion Complete with Mushroom Cap 3 It bgs Complete to Exis Ing 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 1 AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION LAWS. pp IVv /JMI MUM �4 HOUR /ADVANCE NOTICE REQUIRED FOR INSPECTIONS CONTRACTORS SIGNATURE / j//—� ,'(/V� TITLE DATE 9- /7- 7-v ...... ......... _. ___...._.._....... ......_.__ __._.__.......... _.____ ___ _-._ - -- .._. -- -i ' I I e i _-_.—i—. ......................................................_.............._.__._. ._._..___ —_. .�._..._— __—--.. _._ __ —._.._ .._...... __• _•— — ... ....... L GDr P, �y .............. ............ - ___ __ _ s21 __+.._._.......___._....._...._ _.._...... .._._._.._.._.._ ..__ .___._.._ _ _. . _.. ...._ 1 � .__..--------_._._._ _.._....._...._.__. -- ---.. .._ . .-......... _ H aQ _. 4 �Y Fzrr .... _ _....... ._...._. _.......................... ....._ T,yF T DEPARTMENT USE ONLY Application Accepted By ry�'�G Date 7/v�� Area Destruction Inspection By_// 314 Date Employee ID# D� COMM ENTSIn+ef`-or of gilt r45jfr4 SI)411 be c Ir✓„rcin/ obs ;�toaHS�v�1H/ch mjSh�. tier ('pie 'J,�th Q f_�ecfke seg4ll,6 nroc>Cl PE Sc Received Check#/ Amount Permit/ Codes Info By, Cash Remitted Date Service Request# Invoice# Well ID# 14373 ! ( 1�l�” U ARV . EHD 43-08 //�n /�i WELL DESTRUCTION PERMIT 4/30/12 L•(