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MINIMU CONTRACTORS SIGNATURE II AreaArea Zo-Z/ EPARTMENT USE ON Date Application Accepted By Destruction Inspection By COMMENTS Ok)N-QtAk 202/, SAN JOAQUIN COUNTY ENVIRON MENTAL iiSALTHDEPARNE/yr Date 5 / I Employee ID# WELL DESTRUCTION PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPT NON-REFUNDABLE PERMIT PUBLIC WATER SYSTEM 1:] Yes SI° 1868 East HazeIton Avenue - STOCKTON CA 95205-6232 - (209)468-342C CALL 209 953-7697 FOR INSPECTIONS JOB ADDRESS1 151 i ---C"..) -ro ify) 2/5st I int \C)-0( ciTyizip IL CROSS STREET ( A ck_ \ APN Z- 1303 6 ,3 :3 PARCEL SIZE i(-) ) LAND USE APPLICATION # OWNER 1 00 't i ck rdt.--h1-21,/ PHONE OWNER ADDRESS il/V1--e, CITY/STATE/ZIP CONTRACTOR 19/1 lig4/1/1 D r/ L ( lit PHONE a_060 cth,r) 01 0,4 , CONTRACTOR ADDRESS 4--)v v....-4><, 1 CITY/STATE/ZIP F 1 vb2.4., 4 r_ C-57 WELL DRILLING LICENSE NUMBER OW -(12 a EXPIRATION DATE Z/ &'- PERFORATION CONTRACTOR PHONE • PERFORATION CONTRACTOR ADDRESS CITY/STATE/ZIP C-57 Well Drilling License Number Expiration Datil i k^:_'- 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 0 Dry ID Replacement Well 0 Caved In 0 Pit Well Xlnactive El Test Hole Detected / Suspected Well Water 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 0 No 0 Yes ft below ground surface (bgs) Hole Diameter inches Well Conductor Casing 0 Yes 0 No Depth of Conductor Casing ft bgs Diameter of Conductor Casing inches Well Casing Diameter inches Total Depth ft Depth to Water ft Depth of Casing ft.bgs - DEsTRucTioN SPECIFICATION -t-LP Sealing Material from ft bgs to 0 ft bgs Filler Materialt from ft bgs to / _ ft bgs , Well casing to be perforated by one of the following methods: from ft bgs to ft bgs 0 Mills Knife Number of cuts every ft and / or i( / O Explosives 0 Detonating cord 0 with projectiles every ft 0 without projectile C , 0 Detonating cord and boosters 0 with projectiles every ft 0 without projectile ' ( 0 Other Sealin Cement (94 lb bag / 5-6 gal water) Sand Cement sack mix / 7 gal water Bentonite Pellets ...kagLitonite (20% so s • acturer Spec % solids % Name Specs on File Specs Submitted Placement Method Pumpe Free Fall Other Seal Completion Complete wi 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. :SS3111303V 311S R AD ANCE NOTICE REQUIRED FOR INSPECJA7 TITLE 1:).01 DATE el PE Codes SC Info Received By (...0 heci* e Amount Remitted Date Permit/ Service Re guest # Invoice # Well ID# / ash i Wil P.1-1 21 I NOO402_ END 43-08 revised 4/14/18 WELL DESTRUCTION PERMIT