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rte.)4ve4c6j, • II r 1 .1 WELL DESTRUCTION PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPT NON-REFUNDABLE PERMIT PUBUC WATER SYSTEM DYes D No 1868 East Hazelton Avenue. STOCKTON CA 95205-6232 - (209)468-3420 CALL 209 953-7697 FOR INSP C Joe ADDRESS 04.1- iv. if A, 61,4„./ 4 r arm,. >lig /0/ I-4,a. do • . CROSS STREET PAit-Afees rs• APN ia AS - 1W- aSz, PARCEL SIZE LAND USE APPLICATION # OWNER frifilfi, 4 0 Ad r PHONE OWNER ADDRESS le 5 ,if. 14 #41 C401.."/ .6.r" • CrrYISTATEIZip ift I ifiVre - 4 4 441 • " CONTRACTOR eANe/244,- .1 .5,04.1.5 y•ve. pHow( Apatp) r 3 p.-n 34 CONTRACTOR ADDRESS ,f4 a* 61.,etri- er crryisTATErzip • 50,,e0.-ot1 CAL q1-,' C-S7 WELL DRILLING LICENSE NUMBER # AS-7V '17 EXPIRATION DATE /1 P-O A./ PERFORATION CONTRACTOR PHONE PERFORATION CONTRACTOR ADDRESS CITY/STATE/ZIP 0 C-57 Well Drilling Ucense 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 ID Dry 0 Replacement Well 0 Caved In 0 Pit Well pc Inactive 0 Test Hole Detected / Suspected Well Water Contaminant(s) Adjacent property with contamination (Address) Known Soil / Water contaminants at adjacent property EXISTING WELL CONSTRUCTION DETAIL: • .en Bottom 0 Gravel Pack 0 Uncased 0 Other c.,/--0 Well Log copy attached 0 Yes No Grout S No 0 Yes ft below ground surface (bgs) Hole Diameter inches Well Conductor Casing 0 Yes 0 No of Conduc -ftbgs Diameter of Conductor Casing inches Well Casing Diameter 4' ' Inches Total Depth L ,,,,ii Itteithatella4e7 ft Depth of Casing ft bgs DESTRUCTION SPECIFICATION ze, u.l.e-t( _pot) $1,01".A- 4, ek. Sealing Material from rit-bt5-95 ft bgs 'Filler =trial from ft bgs to q411/ Well casing to be perforated by one of the following methods: from ft bgs to ft bgst,A O Mills Knife Number of s every ft end/or ,11., 0 Explosives 0 Detonating cord • with projectiles every ft 0 without projectile 0 Detonating cord and boost , -4 with projectiles every ft 0 without projectile O Other Sealing Material Neat Cemeni, • - . bag /5-6 gal water) Sand Cement sack mix /7 gal water Bentonite Pellets Bentonite (20% solids) anufacturer Spec % solids % Name Specs on File Specs Submitted Placement Method Pumped 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. MI LAM 48 OUR ADVANCE NOTICE REQUIRED F R INSPECTIONS CONTRACTORS SIGNATURE TITLE 09/1/ 04 ,61r DATE 3/ SAO DEPARTMENT Application Accepted By Destruction Inspection ?y Date COMMENTS ink II Gat/ rytt 41- irne revo t sr cio(,70614+ oies1-fu ,1130 F w_evl 01,1m maleoe, USE ONLY Date 3 /6 6?) 4i1c61 0.1tztruYeol . Area .077614 e Employee ID#S S Vriify v611 t fhe L,Jel 6,nnei PE Codes SC Info Received By_ Check#4 Amount cash Remitted Da Permit/ Service Regra Invoice # Well ID# Li3 7 3 I i („0-- 14.54E- 4 /61:).- 2 r3111/ l 1 s4 IA/pool-1B [ eA1' 44 /2/ 717 Lall WELL DESTRUCTION PERMIT END 43-08 revised 4/14/18