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r r <br /> WELL DESTRUCTION PERMIT <br /> PUBLIC WATER SYSTEM❑Yes ❑No <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPT 1668 East Hazelton Avenue-STOCKTON CA 95205-6232-(209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS CITY/ZIP <br /> CROSS STREET -7 0()�( <br /> .APNPARCEL SIz. LAND USE APPLICATION# 'y <br /> d <br /> OWNER ph o-h Pru io-u--.H1 ezc L�G PHONE <br /> OWNER ADDRESS (� -l' CITY/STATTEIZIP <br /> (T <br /> CONTRACTOR CiIO 1Y, V�J I No I III PHONE 9-b - <br /> CONTRACTOR ADDRESS p a R tk �`' CITYISTATEOP <br /> C-57 WELL DRILLING LICENSE NUMBER�� D-7) EXPIRATION DATE <br /> PERFORATION CONTRACTOR�WT PHONE <br /> PERFORATION CONTRACTOR AoDRF33 7 • CITYISTATFJZJP <br /> rl C-57 Well Drilling Licansa Number Fxpiration Data <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 Sa ty Health-Blaster License Number Expiration Date <br /> REASON FOR DESTR X Dry ❑ Replacement Well ❑ Caved In ❑ Pit Well ❑ Inactive ❑ Test Hole <br /> Detected/Suspected Well to ontaminant(s) <br /> Adjacent property with contamination(Address) <br /> Known Soil/Water contaminants at adjacent property <br /> EXISTING WELL CONSTRUCTION DETAILS ❑ Open Bottom ❑ Gravel Pack ❑ Uncased ❑ Other <br /> Well Log Copy attached ❑ Yes ❑ No Grout Seal ❑ No ❑ Yes n below ground surface(bgs) Hole Diameter inches <br /> Well Conductor Casing es ❑ No Depth of Conductor Casing ft bgs Diameter of Conductor Casing inches <br /> Well Casing Diameter inches Total Depth ft Depth to Water ft Depth of Casing ft bgs <br /> DESTRUCTION SPECIFICATION,� <br /> Sealing Material from ft bgs to O It bgs Filler Material —Z-0 fromi _iF15g­s _ft bgs <br /> Well casing to be perforated by one of the following methods: from ft bgs to It 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 It ❑ without projectile <br /> ❑ Other <br /> Sealing Mate- t Cement(94/b bag/5-6 gal water) Sand Cement sack mix/7 gal water Bentonite Pellets <br /> Bentonite(201 solids) ufacturer Spec%solids_% Name Specs on File Specs Submitted <br /> acemen et o umpe Free Fall Other <br /> Seal Completion Complete Mushroom Cap ft bgs Complete t0 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 /> MINI OUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br /> CONTRACTORS SIGNATURE / TITLE �Y��l� V. DATE_t" <br /> � I i <br /> ` <br /> ! <br /> — <br /> — I 0NMECOIJAt <br /> EPgRT 4L <br /> I I <br /> DEPARTMENT USE ONLY I, <br /> Application Accepted By � Data / d Ate. <br /> Destruction Inspection By Date Employ-l <br /> COMMENTS V�tl /eM- 1 w� erri Y .,-&- ' -1 y t CIPc/L' ill �h <br /> r c f; -S n/l A n to YC h c e � in r 12 ra CP 'i Pe <br /> PE SC Received Check#/ Amount Date Permit/ 1 Invoice# WellID# <br /> Codes Info 8 Cas Ramittod .2—Ice Reguast ft <br /> J/ WELL DESTRUCTION PERMIT <br /> iNSA7 <br />