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WELL DESTRUCTION PERMIT PUBLIC WATER SYSTEM [:]Yes ❑ No SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPT 1868 East Hazelton Avenue - STOCKTON CA 95205-6232 . (209) 468-3420 NON-REFUNDABLE PERMIT CALL (2091953-7697 FOR INSPECTIONS EXPIRES 7 YEAR FROM DATE ISSUED JOB ADDRESS 5l S fA V -I lI ) +�C) S+ CITY/ZIP Wnev b � t"� Q �. Cis ojS 1 ,t CROSS STREET C 11G S V) V S "} APN 015` 3'10 — GO PARCEL SIZE .46 LAND USE APPLICATION # OWNER L I S a T2y1 h % V) S PHONE i2cnq anio-3%sca_ OWNERADDRESS` �� Jog CITY/STATE/ZIP Laof 474157C? L) 1�L> t-� CONTRACTOR V I!{ l i c k IJ r I % Y) 2 S^^ PHONE Jy q 3 69 - a 77c CONTRACTOR ADDRESS P. C 9 o x 4:) CITY/STATE/ZIP IJCt IL CA G S GS ��yy�� r� *,02".32S X C-57 WELL DRILLING LICENSE NUMBERMo/"I�.3 21 S EXPIRATIONDATE r1 PERFORATION CONTRACTOR Ty 10r AA C1 r 1 I I CAY11Sy U41 Sir \ r � PHONEq I G X77/`/7i•^�urd / y.7 1 '(9 Or -7 ` PERFORATION CONTRACTOR ADDRESS _I 53 0 H a �J M c 'y) R D• Sk 1L-CITY/STATE/ZIP�.i A Z � -7 qK L S T t i) d CA q 33 I Dr ❑ C-57 Well Drilling ; V 39y License Number Expiration Date I Number 9 CA ooZoi `33 Expiration Date I 2 Bureau of Alcohol, Tobacco and Firearms - Users of High Explosives License 1 CHP Hazardous Material Transportation for Explosives License Number Expiration Date San Joaquin County Sheriff -Coroner Explosives Application and Permit License Number d O ` O Expiration Date a1 Califomia Occupational Safety Health - Blaster License Number 1301 Expiration Date L $ 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 �RL Open Bottom ❑ Gravel Pack ❑ Uncased ❑ Other Well Log copy attached ❑ Yes )A No Grout Seal ❑ No ❑ Yes ft below ground surface (bgs) Hole Diameter inches Well Conductor Casing)61 Yes ❑ No Depth of Conductor Casing N j ft bgs Diameter of Conductor Casing 1!1 Well Casing Diameter j . inches Total Depth ao ft Depth to Water.36 ft Depth of Casing j2Cft bgs DESTRUCTION SPECIFICATION I I I I l �p 5 Sealing Material from ) �C` ft bgs to S ft bgs Filler Material ) 0 •; eN K from ft bgs to 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 X Explosives ❑ Detonating cord ❑ with projectiles every ft ❑ without projectile `3d Detonating cord and boosters ❑ With projectiles every 1.�_ ft ❑ Without projectile ❑ Other Sealing Material Neat Cement (94 lb bag /5-6 gal water) Sand Cement 10.3 sack mix /7 gal water Bentonite Pellets Bentonite (20% solids) Manufacturer Spec % solids_% Name Specs on File Specs Submitted Placement Method X Pumped Free Fall Other Seal Completion Complete with Mushroom Cap S 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 REQUIRED FOR INSPECTIONS �y�Nr t c� PrC s I �U CONTRACTORS SIGNATURE TITLE I t ✓) � DATE DEPARTMENT Application Accepted By PE Codes EHD 43-08 SC Info Received B Ch / Cash Amount Remitted Date PermlU Service Re uest# Invoice # Well ID# �3-�� ► s � Sas WELL DESTRUCTION PERMIT revised 4/14/18