WP0041537 - Laserfiche WebLink

Home Browse Search

' WELL DESTRUCTION PERMIT • PUBLIC WATER SYSTEM ❑Yes YNo 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 JOB ADDRESS V�'�(� ScLm Aq c es KA CITY/AP T^�r11Q.(.-�/ l S CROSS STREET CO .APNZ7O 'IW0 .50 PARCEL SIZE21JAND USE APPLICATIONp#� OWNER — LL PHONE rJ - -I 1 _�tZX�l`r� 8-1 OWNER ADDRESS O ITY/STATE/ZIP�'J1aAA gQL�'�Q(�, COLONC-5 CONTRACTOR PHONE 5 W S— II CONTRACTOR ADDRESS, CITY/STATEIZIP MncieS�-a.CA9S 35� C-57 WELL DRILLING LICENSE NUMBER 2.qD 6 L3 EXPIRATION DATE PERFORATION CONTRACTOR PHONE PERFORATION CONTRACTOR ADDRESS CITY/STATE/ZIP C-57 Well Drilling License Number 2908 1 3 Expiration Dates-3►-2 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 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 ❑ Open Bottom Gravel Pack ❑ Uncased ❑ Other Well Log copy attached ❑ Yes ❑ No Grout Seal ❑ No Yes ft below ground surface(logs) Hole Diameter inches Well Conductor Casing❑ Yes ❑ No Depth of QQnPuctor Casing ft bgs Diameter of Conductor Casing inches Well Casing Diameter_(C)f_inches Total Dept "300ft Depth to Water ft Depth of Casing $nn ft bgs DES'I RUCTION SPECIFICATION lv- s cy(- Sealing Material from bgs to JD Q ft bgs Filler Material GV-CLV e from t 0 0 it bgs to J 0 ft 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 ❑ Otlter Sealing Material Neat Cement(94 Ib bag/5-6 gal water) Sand Cement 10 sack mix/7 gal water Bentonite Pellets Bentonite(20%solids) facturer Spec%solids_% Name Specs on File Specs Submitted Placement Method Pumped Free Fall Other Seal Completion Complete wn shroom Cap ft 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 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 REQUI ECTIONS CONTRACTORS SIGNATURE E DATE19 I I - _ I pr+A--�, - C tci�r 7flo' 90, f DEPARTMENT USE ONLY Np Application Accepted By — C Date /,21 ,,h, , Area /1.:(.ve Destruction Inspection By // Date Employee ID# Dff COMMENTS n I(. ��. / /E'111 i IS�JN PE SC Received hec Amount Date Permltl Invoice# Well ID# Codes Info 8 a Remitted ^^ �,� yt/ EHD 43-08 WELL DESTRUCTION PERMIT revised 4/14/18