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WELL DESTRUCTION PERMIT PUBLIC WATER SYSTEM ❑Yes ❑No SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPT 1868 East Hazelton Avenue-STOCKTON CA 95205-6232 -(209)468-3420 NON-REFUNDA13LE(�PERMIT CALL(2109 953-7697 FOR INSPECTIONS EXPIRES 1YEAR FROM DATE ISSUED JOB ADDRESS J S FC�, 1�)1'�t� t� Y CITY/7iP ACSI/D A' C1 f' 5220 CROSS STREET.\Kf n Y�e ',r`,k R 17. APN OU S' 270- 15 PARCELSIZE•�2 LAND USE APPLICATION# e OWNER Kt"l-F �N), e- AJ �t)'.`� L `1 PHONE-747/ OWNER ADDRESS -7r)-7 S`UjM NA,"T I -,V Z S, �..)(•A-/ CITY/STATE/ZIPy CI �jK f C(NN7-7� 5 L 11 CONTRACTOR \)CJI\Z I I„/r,I\ ,`�A y�f PHONE 9011 3&` t_ � / /9 J CONTRACTOR ADDRESS 1 o &;)A 4�( �7 CITY/STATE/ZIP C?I1+I C A ,X,C-57 WELL DRILLING LICENSE NUMBER ( -I LI 7 S 7 EXPIRATION DATE-7- Q1- PERFORATION CONTRACTOR PHONE PERFORATION CONTRACTOR ADDRESS CITY/STATEIZIP ❑ 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 N 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 3A Open Bottom ❑ Gravel Pack ❑ Uncased ❑ Other r7 Well Log copy attached ❑ Yes M No Grout Seal ❑ No ]9 Yes l�ft below ground surface(bgs) Hole Diameter u inches Well Conductor Casing❑ Yes )6 No Depth of Conductor Casing ft bgs Diameter of Conductor Casing inches Well Casing Diameter_inches Total Depth C ft Depth to Water 1 U ft Depth of Casing ft bgs DES FR U(TION S PF.(I FIC ATION SealingMaterial from c1,63 �� g ft bgs 1�� ft bgs to J ft bgs Filler Material SG K from ft bgs to 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/b bag/5-6 gal wafer) Sand Cement I(' sack mix/7 gal water Bentonite Pellets Bentonite(20%solids) Manufacturer Spec%solids_% Name Specs on File Specs Submitted Placement Method Pumped Free Fall Other Seal Completion Complete with Mushroom Cap > It 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 to 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 INSPECTIONS CONTRACTORS SIGNATURE� J/7��tL/LC^ TTLE �(1`e' 1 rC` ,Ae�JATE �I 17 ��', ^ L q ►�L lZ D Z F r. V) W t 1\ r, 1391 7qpqYq�F� Q � 9 DEPARTMENT USE ONLY Application Accepted By 1�' Date �i1,711,`� ,W) j Area 1 y V�RO/V��Couiv CDestruction OMMENTS Inspection By - Date �%7��! Employee ID# J DFpgR�,N PE SC Received (rhes Amount ate Perm1U Invoice# Well ID# Codes Info B Cash Remitted ervice Re uest# L13-73k, l ir l � 'IT EHD 43-08 WELL DESTRUCTION PERMIT revised 4/14/18