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HJ9I9VANCE NOTICE REQUIRED FO / INSPECTIONS
<br />TITLE • e'e- , DATE CONTRACTORS SIGNATURE
<br />-4-94—
<br />WELL DESTRUCTION PERMIT
<br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPT
<br />NON-REFUNDABLE PERMIT
<br />PUBLIC WATER SYSTEM []Yes A No
<br />1868 East Hazelton Avenue - STOCKTON CA 95205-6232 - (209) 468-342(
<br />CALL 209 953.7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED ,
<br />JOB ADDRESS ac g.Aetsf€41. 0 9- 0 91 /eel c,,,dzip Fie) 6-1,,' e,,,i 44,,,, 04 . #c 331
<br />CROss STREET ez. DakAbe, $7" APN /93-'07-41*--19 PARCEL SIZE LAND USE APPLICATION #
<br />OWNER_ F.,e ,4.,jc4.,,r/2 -ne.,4,e 7-4-,e "4/44 /...44. PHONE (4/12 V - - 571PD
<br />OWNER ADDRESS I?,e,D /frii•Pen-., ,..5116.4. 4,7 CITY/STATE/ZIP 1.47-hcgop, e,e; • 9 ra 3o
<br />CONTRACTOR 9.40/6/00- SONS /me. PHoNE641/6-32. - .1
<br />CONTRACTOR ADDRESS / 9-3$ V 121,e,i ?VP er. CITY/STATE/ZIP 66•Aftp,e_A eft- 1
<br />C-57 WELL DRILLING LICE E itslyMBER i/S7)4 , EXPIRATION DATE 7/a//201,24,
<br />PERFORATION CONTRACTOR e /imp 1/740:ilSereprife, PHONE 9/, d>/-- 6-2244-
<br />PERFORATION CONTRACTOR ADDRESS 96-03 /142/6/2W a 8 CITY/STATE/ZIP 6:241...s"&, /t', 41 98.3/2
<br />0 C-57 Well Drilling -46-3 9 License Number Arlrale Expiration Date
<br />Bureau of Alcohol, Tobacco and Firearms - Users of High Explosives License Number ci - CA - °';') ‘)Ae. Expiration Date ::1-0i
<br />CHP Hazardous Material Transportation for Explosives License Number Othe, • 1"bi11 I i,:L4=EXPiration Date Al "
<br />San Joaquin County Sheriff-Coroner Explosives Application and Permit License Number dl -DO Expiration Date IN
<br />Califomia Occupational Safety Health - Blaster License Number 9 ;to i Expiration Date 0- lir
<br />REASON FOR DEsTRUCT1ON 0 Dry X Replacement Well 0 Caved In 0 Pit Well 0 Inactive 0 Test Hole
<br />Detected / Suspected Well Water Contaminant(s)
<br />Adjacent property with contamination (Address)
<br />Known Soil / Water contaminants at adjacent property
<br />•
<br />EXISTING WELL CONSTRUCTION DETAILS 0 Open Bottom 0 Gravel Pack 0 Uncased 0 Other
<br />Well Log copy attached 0 Yes' eyo Grout Seal 0 No 0 Yes ft below ground surface (bgs) Hole Diameter fet inches
<br />Well Conductor Casing 0 Yes le No Depth of Conductor Casing ft bgs Diameter of Conductor Casing inches
<br />Well Casing Diameter it, tf inches Total Depth /#0, ft's Depth to Water iler ft Depth of Casing Alb ft bgs
<br />DESTRUCTION SPECIFICATION
<br />Sealing Material from 4 MAI ft bgs to 7-70, ft bgs Filler Material if 6-Of-I< Stil-711/) from e ft bgs to / Bk. ft bgs 44 i, Well casing to be perforated by one of the following methods: ft bgs to ft bgs
<br />0 Mills Knife • Number of cuts every ft and / or• ,
<br />,S1 Explosives. 1*Detonatingcord j;! with projectiles every / ft 0 without projectile
<br />'0 cord and boosters 0 with projectiles every ft 0 without projectile ,Detonating
<br />0 Other
<br />Sealing Material Neat Cement'.(94 /b bag / 5-6 gal water) Sand Cement /7---'.. . sack mix I 7 gal water Bentonite Pellets
<br />Bentonite (20%*1,10s) Ma acturer Spec % solids % Name , Specs on File Specs Submitted ,
<br />Placement Method ",', i, Free Fall Other , ,
<br />Seal Completion : X Complete with Mushroom Cap ..S ft bgs Complete to Existing Surface Pad
<br />I HEREBY CERTIFY THAtt1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN
<br />JOAQUIN COUNTY ORIDI4N,CES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS
<br />CURRENT AND ACTIVE WITH ,THE CA121FORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL
<br />WORKERS COMPENSATION, LAWS.
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<br />' HEiq L. iR ON Ty, M i 1 1 I I 1 I I I I I I I I I I I I I I i I I I 1 I I I I I I 1 I I
<br />DEPARTMENT USE USE ONLY
<br />
<br />Application Accepted By Date yd 7A 1 Area C-T-Z__./.._ I/ 9 q Employee ID# its
<br />
<br />Grout Inspection By f\ ,Cy•-.....---___----- Date 1 VI (7 i E SPECIAL Well Permit
<br />
<br />Pump Inspection By Date I 1 WAIVER Received
<br />
<br />Soil Boring Inspection By Date Constructed Well Depth
<br />COMMENTS
<br />PE
<br />Codes
<br />SC
<br />Info
<br />Received Check#/ Amount
<br />Remitted Dat Permit/
<br />Service Request # Invoice # Well ID#
<br />H 3 741 it "'-
<br />edg.
<br />143—'
<br />Cash
<br />$.3 d 3- 4 2.--1 1,1 1po0.7.1
<br />_
<br />SAN
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<br />/6?sy,tv WELL /PUMP PERMIT EHD 43-06 6/11/2019
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