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• '` WELL DESTRUCTION PERMIT <br /> PUBLIC WATER SYSTEM ❑Yes J%ft <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 INSPECTIONS EXlPIRES I YEAR FROM DATE ISSUED <br /> JOB ADDRESS �` C"/LP 953,32 r w <br /> 1 u i <br /> CROSS STREETLe,.-, <br /> S APN a�1 a a`� 3 PARCEL SIZE LAND USE APPLICATION# E <br /> OWNER PHONE a°q - 96q - Iga3 <br /> OWNER ADDRESS 3 4 ♦: CT/ISTATEZP 1"I`R�N 0_-11 -�1 p <br /> ��� .• <br /> CONTRACTOR f� w• PHONE D-0 —1}'-+ M L--)- 7 34, <br /> CONTRACTOR ADDRESS 3 0 O r CITYISTATE/ZIP 1 r I D`� LQ• R� O Y <br /> C-57 WELL DRILLING LICENSE NUMBER �- ExPIRATION DATE <br /> PERFORATION CONTRACTOR PHONE <br /> PERFORATION CONTRACTOR ADDRESS CITY/STATEZP <br /> ❑ C-57 Well Drilling License Number 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 WI 1 ❑ Caved In ❑ Pit Well 4!9 Inactive ❑ Test Hole <br /> Detected/Suspected Well Water Contaminant(s) N <br /> Adjacent property with contamination(Address) <br /> Known Soil/Water contaminants at adjacent property K ha <br /> Ex18Tmo WELL CONSTRUCTION DETAILS ❑ Open Bottom ❑ Gravel Pack ❑ Uncased ❑ Other <br /> Well Lag copy attached ❑ Yes b No Grout Seal ❑ No ❑ Yes R below ground surface(bgs) Hole Diameter N inches <br /> Well Conductor Casing❑ Yes Wi No Depth of Conductor Casing�It bgs Diameter of Conductor Casing inches <br /> Well Casing Diameter_, inches Total Depth 10 It Depth to Waterft Depth of Casing O ft logs <br /> DESTRUCTION SPECIFICA710� <br /> Sealing Material from g� It bgs to It bgs Filler Material IV from It bgs to ft bgs <br /> Well casing to be perforated by one of the following methods: from It logs to ft bgs <br /> ❑ Mills Knife Number of cuts every ft and/or <br /> ❑ Explosives❑ Detonating cord ❑ with projectiles every ft ❑ without projectile <br /> ❑ Detonating cord and boosters ❑ with projectiles every ft ❑ without projectile <br /> ❑ Other <br /> Sealing Material Neat Cement(94 lb bag/5-6 gal water) Sand Cement sack mix/7 gal water Bentonite Pallets <br /> Bentonite(20%solids) ufacturer Spec%solids7- % Name trCOy Specs on File Specs Submitted <br /> Placement Method Free Fail Other <br /> Seal Completion Complete with Mushroom Cap j ft 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 /> MWI�48 OUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br /> CONTRACTORS SIGNATURE TITLE yo ti r v,',.O r DATE I( '�3 •'a.a <br /> yy\ R �ILJ4�N <br /> r <br /> �vFo <br /> S,4N NO 23 ?420 <br /> 'Ii VI�UM�NAUNTY <br /> PgRNM <br /> DEPARTMENT USE ONLY <br /> Application Accepted By � Date ( /�% Oi7 Area S /r'Gf✓�1�'cC1 <br /> Destruction Inspection By1- Date -Z- Employee ID# <br /> COMMENTS e- ) I "She <br /> PE SC Received Check#/ Amount Date Pernw Invoice# Well IDS <br /> Codes Info Cash Remitted Service Re nest 0 <br /> LIS 1.3 1 •i SGZ_ III, _ 2 <br /> EHD 43-08 ,JIn/r(' /'/�/'I WELL DESTRUCTION PERMIT <br /> revised 4114/18 ( V 4,n, <br />