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WELL DESTRUCTION PERMIT _/ PUBLIC WATER SYSTEM ❑Yes�* SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPT 1868 East Hazelton Avenue-STOCKTON CA 95205-6232 -(209)468-3420 NOS',""""^ABLE PERMIT CAL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED 'Tracv 9531 JOB ADDKtbJ L� (� CITY/hp v' r CROSS STREET APN�'1O I T O �Q _PARCEL SIZE�QC'] TI AND USE APPLICAON# OWNER I-S r L•+ PHONE C •� O [� OWNER ADDRESS �� Crow \_1_l Y>�✓d T� l.•.lT Cir•-•��1: CITY/STATE21P✓ATl r) s CONTRACTOR Q 1 C 1 ` PHONE 5 1~) G , CONTRACTOR ADDRESS 1 -L O L- ^ o p, CITY1STATE/LPM O 4 f,5 o, C A,153 Jb C-57 WELL DRILLING LICENSE NUMBER ;--1O U 1 S EXPIRATION CDATE 'C ,7`-3 1- 2� ?- PERFORATION CONTRACTOR • PHONE ,7 Y 5-111 U J ^n o PERF RATION CONTRACTOR ADDRESS 1119� CITYISTATE/ZIP r! 6 A 67 S+0• 1,n CS3 54, C-57 Well Drilling r License Number 2q0 U�3 Expiration DaterJ_3►_�C1� 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 Contaminants) 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 ftbelow ground surface(bgs) Hole Diameter inches Well Conductor Casing❑ es ❑ No Depth of Conductor Casing ft bgs Diameter of Conductor Casing inches Well Casing Diameter inches Total Depth LVQO ft Depth to Water ft Depth of Casing __it bgs DESTRUCTION SPECIFICATION1 A� G� / Sealing Material from Q ft bgs to ftbgs Filler Material_ G� y e from ft bgs to W ftbgs el asing to beerforated by one of the followina methods: T from ft bgs to�Q ftbgs ills Knife _Number of cuts every ft and/or ❑ Explosives❑ Detonating cord ❑ with projectiles every It ❑ without projectile ❑ Detonating cord and boosters ❑ with projectiles every ft ❑ without projectile ❑ Other Sealing Material Neat Cement 94 Ib bag/5-6 gal water) Sand Cement sack mix/7 gal water Bentonite Pellets Bentonite(20%.solids Pan acturer Spec%solids % Name Specs on File Specs Submitted Placement Method umped Free Fall Other Seal Completion Complete wI 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 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 I TIONS CONTRACTORS SIGNATURE V TITLE W. M •' DATE�,��4 I Of A - : RFC Z DEPARTMENT USE ONLY H F gQUjN 20 Application Accepted By L I`— L Date ) ! +v„ ✓ Area Destruction Inspection By_Jq1- Date 2 Employee ID# S� COMMENTS T PE SC Received k#/ Amount Permit/ Codes Info B Cash Remitted Date ��•; o Invoice# WeIIID# EHD 43-08 WELL DESTRUCTION PERMIT revised 4/14118