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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-REFUNDABLE PERMIT CALL 209)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED JOBADDRESS 21014 Comstock Rd C"JZIP T,J nden,C'A c),?36 CROSS STREET Fine Rd APN 0 9 1 '�[1 O n 2 PARCEL SIZE LAND USE APPLICATION# OWNER Kathryn Anr7Pr--nn T-rI7ci- PHONE OWNER ADDRESS P-0 n cyy r5 5i CITY/STATE/ZIP L i n d e n',CA 9 r;?R G CONTRACTOR Piiry-i aIlCe nr'11]Qr_s' l(VE PHONE 209 887 35SQ CONTRACTOR ADDRESS P (} Rnx F d CFYISTATE/ZIP Linden,CA 95236 .. C-57 WELL DRILLING LICENSE NUMBER 3 7 7 9 2-'3"" EXPIRATION DATE 7/31 L21 1 (� PERFORATION CONTRACTORJf I — PHONE CFI PERFORATION CONTRACTOR ADDRESS CITYISTATEIZIP D ❑ C-57 Well Drilling License Number Expirati�v Date Bureau of Alcohol,Tobacco and Firearms-Users of High Explosives License Number Expirati��jn^�+'4 ,4 car,,.� CHP Hazardous Material Transportation for Explosives License Number Expirati 114'ht'rRON"', qV COL T San Joaquin County Sheriff-Coroner Explosives Application and Permit License Number Expiration Date4-6 Y California Occupational Safety Health-Blaster License Number Expiration Date T REASON FOR DESTRUCTION ❑ Dry ❑ Replacement Well ❑ Caved In ❑ Pit Well Inactive ❑ Test Hole Detected/Suspected Well Water Contaminant(s) �l(�(ti Adjacent property with contamination(Address) Known Soil/Water contaminants at adjacent property EXISTING WELL CONSTRUCTION DETAILS X Open Bottom ❑ Gravel Pack ❑ Uncased ❑ Other Well Log copy attached ❑ Yes 0 No Grout Seal ❑ No 14 Yes ft below ground surface(bgs) Hole Diameter 167 inches Well Conductor Casing ❑ Yes 14 No Depth of Conductor Casing ft bgs_ Diameter of Conductor Casing inches Well Casing Diameter__J�p _inches Tota1 Depth 1F3 It Depth to Water ft Depth of Casin « ft bgs DESTRUCTION SPECIrFICATION Sealing Material from _eft bgs to I$3 ft bgs Filler Material 't PU-it-r from 0 ft bgs to ? nom ft bgs Well casing to be Perforated by one of the following methods: 'Pti e?if� from 'ZI It bgs to ft bgs )K Mills Knife 4 Number of cuts every .5- ftand/or ❑ Explosives ❑ Detonating cord ❑ with projectiles every ft ❑ without projectile ❑ Detonating cord and boosters ❑ with projectiles every ft O without projectile ❑ Other Sealing Material Neat Cement(94 lb bag/5-6 gal water) Sand Cement 10. 3 sack mix/7 gal water Bentonite Pellets Bentonite(20%solids) Maoufacturer Spec%solids % Name Specs on File Specs Submitted Placement Method Free Fall Other Seal Completion Complete with Mushroom Cap 3 F-)= ft bgso I e 09- ti g I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACC RDANCE 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. i IMUM 4 UR ADVANCE NOTICE REQUIRED FOR IN PECTIONS CONTRACTORS SIGNATURE TITLE DATE10 2O Z jXw," jW LP (} j 94WCA ell 4 petting{,ui 1 1J �51t I ! i DEPARTMENT USE ONLY (� Application Accepted ByDate f�/JS� ''� Area �J Destruction Inspection By.4A4-!20 - I' Date �Z� Employee ID# COMMENTS Plb�,fCl'✓1 Cpl)ro( ncn'>�r �,Ipp�y knl �l�»c; �M Slee) /o PE Sc Received Check#I Amount Permit/ Codes Info B Cash Remitted Date Service Requ st# Invoice# Well ID# N3'7y 4 3aS EHC 434/1 nrf^� <! ll/ f�/R� WELL DESTRUCTION PERMIT revised 4/14J1II l�o l�l�V