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WELL DESTRUCTION PERMIT <br /> PUBLIC WATER SYSTEM ❑Yes$j No <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPT 1868 East Hazelton Avenue-STOCKTON CA 95205.6232!-(`209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIC EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS ,. E. \rJoackwarAV C CITY/ZIP M4LnA-C CQ 9 S 33""t <br /> CROSS STREET fTiV f Y APN O ISO 0 6 PARCEL SIZE_5 LAND USE APPLICATION# <br /> OWNER ^ � •P PHONE y <br /> OWNER ADDRESS J(711 7 1 /�St. /. CITY/STATE/ZIPaa K e <br /> 41 . CA 9554 <br /> I\ <br /> CONTRACTOR'r-n L 1 1 ck�b r;'ros. 10\ X\;Aa eT�A. <br /> m. 1.f . PHONE 5 4,5-mR S <br /> CONTRACTOR ADDRESS I `11d 91A. �j CITY/STATE/ZIP DA 1-1 V 'CA <br /> C-57 WELL DRILLING LICENSE NUMBER 2-410�� ;J EXPIRATION DATE <br /> PERFORATION CONTRACTOR PHONE <br /> PERFORATION CONTRACTOR ADDRESS CITY/STATE/ZIP <br /> I <br /> C-57 Well Drilling License Number29'10Q 1 Expiration Date <br /> Bureau of Alcohol,Tobacco and Firearms-Users of High Explosives License Number Expiration Date <br /> CHP Hazardous Material Transportation for Explosives License Number Expiration Date <br /> San Joaquin County Sheriff-Coroner Explosives Application and Permit License Number Expiration Date <br /> California Occupational Safety Health-Blaster License Number Expiration Date <br /> REASON FOR DESTRUCTION ❑ Dry ❑ Replacement Well ❑ Caved In ❑ Pit Well Inactive ❑ Test Hole <br /> Detected/Suspected Well Water Contaminants) <br /> Adjacent property with contamination(Address) <br /> Known Soil/Water contaminants at adjacent property <br /> EXISTING WELL CONSTRUCTION ET LS ❑ Open Bottom Gravel Pack ❑ Uncased ❑ Other <br /> Well Log copy attached ❑ Yes X <br /> No Grout Seal ❑ No ❑ Yes It below ground surface(bgs) Hole Diameter inches <br /> Well Conductor Casing❑ Yes ❑ No Depth of Conductor Casing ft bgs Diameter of Conductor Casing inches <br /> Well Casing Diameter__inches Total Depth_JC It Depth to Water J_a It Depth of Casing R bgs <br /> DESTRL(TION SPECIFICATION <br /> Sealing Material from 0 bgs to 103 ft bgs Flller Material from It bgs to ft bgs <br /> Well casing to be perforated by one of the following methods: from It bgs to ft bgs <br /> ❑ Mills Knife Number of cuts every ft and/or <br /> ❑ Explosives❑ Detonating cord ❑ with projectiles every It ❑ without projectile <br /> ❑ Detonating cord and boosters ❑ with projectiles every It ❑ without projectile <br /> ❑ Other <br /> Sealing Material Neat Cement(94 Ib bag/5-6 gal water) Sand Cement sack mix/7 gal water Bentonite Pellets <br /> Bentonite(20%solids) ufacturer Spec%solids_% Name Specs on File Specs Submitted <br /> Placement Method Pumped Free Fall Other <br /> Seal Completion Comple shroom Cap �S It bgs Complete to Existing Surface Pad <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> MINIMUM 24 HOUR ADVANCE NOTICE REQUIRE FdR IN�F ,CJ}ANS <br /> CONTRACTORS SIGNATURE ITLE F oI�'�1�V. DATE 9-XI <br /> PA MENT <br /> RECOVED <br /> -I- <br /> EAR 0 8 2021 <br /> _ SAN JOPQUIN COUNTY <br /> ENVIF ONMENTAL <br /> HEALTH DEPARTMENT <br /> y <br /> A R M ENT USE ON L <br /> Application Accepted By Date blb Area <br /> Destruction Inspec' n By Date 1 Employee I # S <br /> COMMENTS <br /> PE SC Receive Check#/ Amount Date Permit/ Invoice# Well ID# <br /> Codes Info Ca emitted ervlce Re uest# <br /> ZI H 1 <br /> EHD 43-08 WELL DESTRUCTION PERMIT <br /> 70/5/07 <br />