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WELL DESTRUCTION PERMIT PUIBUC WATER SYSTEM O Yes 0 No SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPT 1868 East Hazelton Avenue - STOCKTON CA 96205-6232 - (209)468-3420 NON-REFUNDABLE PERMIT CALL 209 953-7697 F JOB ADDRESS CI 0 0 ki , cso uu 1.-es Rat crry,zp 1,-. 1:4_i-w}p,..) gs-,....a.....0 CROSS STREET 1-)'-' APN OCT, .-7 00 c.- PARCEL a — . SIZE LAND USE APPLICATION # ., OWNER pt-1 /44A,, t_i_z„ PHONE OWNER ADDRESS i::30 H CL illi ro-te I-11 .11:- is errasTATE0, R--hcArzt-uy. CONTRACTOR C. c‹ )+4° Ihi 4A, i b rl U t ri i PHONE a t.i (4,& . ül 0(4 CONTRACTOR ADDRESS P D lack: Lf4t 0 CIMSTATEIZIP 1 "I# •.-Y L_ 0-57 WELL DRILLING LICENSE NUMBER t bt-c--t tc- if 2) EXPIRATION DATE CI ( /9----..- PERFORATION CONTRACTOR PHONE PERFORATION CONTRACTOR ADDRESS CITY/STATE/ZIP 0 C-57 Well Drilling License Number Expiration Date 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?ffik Dry 0 Replacement Well 0 Caved In 0 Pit Well 0 Inactive 0 Test Hole Detected I Suspected Well W ter Contaminant(s) Adjacent property with contamination (Address) Known Soil / Water contaminants at adjacent property EXISTING WELL CONSTRUCTION DETAILS 0 Open Bottom 0 Gravel Pack 0 Uncased 0 Other Well Log copy attached 0 Yes 0 No Grout Seal 1:1 No 0 Yes ft below ground surface (bgs) Hole Diameter inches Well Conductor Casing 0 Na Depth of Conc,451pcCasing ft bgs Diameter of Conductor Casing inches .0:g'es Well Casing Diameter inches Total Depth 'IS ki ft Depth to Water ft Depth of Casing ft bgs ‘ . DESTRUCTION SPECIFICATION .3 .--1,. N Sealing Material from ft bgs to it bgs Filler Material from ----- ft busto-glj ft bgs Well casing to be perforated by one of the following methods: from ft bgs to ft bgs El Mills Knife Number of cuts every ft end/or O Explosives 0 Detonating cord 0 with projectiles every ft 0 without projectile 0 Detonating cord and boosters 0 with projectiles every ft 0 without projectile 0 Other Sealing Material Neat Cement (94 lb bag / 5-6 gal water) Sand Cement sack mix /7 gal water Bentonite Pellets (,113entonite 120% solidgr-• acturer Spec % solids % Name Specs on File Specs Submitted Placement ivre-moa Pu Free Fall Other Seal Completion Complete with Mushroom 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. CONTRACTORS SIGNATURE MINIM UNk H R ADVA CE NOTICE REQUIRED FOR INSPECTIONS TITLE IC)n I. 1--"W" DATE H -.7 f 24 ! A I i A .. J4, ., t f(4(../i4e01) s A 0,4 FA no 1 • d DEPARTMENT USE ONLY Date kea t Employee I Application Accepted By Destruction Inspection By COMMENTS v4p13., r c.yx a bsfru,; laYIK / „I kTleh -r %NCI cz4t- she, i riot be cleci,tti fb ei cite fri 13h rytterce i'fh elf&IIye ww./iwj p e(77/1/ rPS: Date PE Codes SC Received Info .13), , Check/ Cash Amount Remitted Date Permit/ Service Request # Invoice # Well !Di) LiSi=: / 1 ,d&--' oetibi END 43-08 10/5107 //1D7z t1 WELL DESTRUCTION PERMIT