WP0041744 - Laserfiche WebLink

Home Browse Search

WELL DESTRUCTION PERMIT PUBLIC WATER SYSTEM ❑ Yes ❑ No SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 East Hazelton Avenue - STOCKTON CA 95205 - (209) 468-3420 NON-RFFIJNDARLF PFRMIT CALL 1909il 953-7697 Fnw INCPFrTInNS FXPIRFS 1 VFAR FRnm IIATF IccIIGn JOB ADDRESS 1G /7(�J�i !� l�Z CITY/ZIP USE ONLY Z / 1 CROSS STREET e4/J 7 cZ APN Of ;�/ 7 PARCEL SIZE LAND USE APPLICATION # Date OWNER � � (,%v YY)/'L' PHONE Destruction Inspection By `c •Svc,` OWNER ADDRESS Q , I111 tY' 1' W CITY/STATE/ZIP �'t�� 'f+J n (5 <- Employee ID# If" SJ � CONTRACTOR , . L'' !8 ' /'i 1 ///f 4 fes/{%" PHONE I C-, S CONTRACTOR ADDRESS CITY/STATE/ZIP l� �Z Cis 2 C-57 WELL DRILLING LICENSE NUMBER JECe/ Z }j EXPIRATION DATE PERFORATION CONTRACTOR PHONE PERFORATION CONTRACTOR ADDRESS CITY/STATE/ZIP ❑ C-57 Well Drilling License 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 ❑ Dry ❑ Replacement Well ❑ Caved In ❑ Pit Well J4 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 ❑ Open Bottom ❑ Gravel Pack ❑ Uncased ❑ Other Well Log copy attached ❑ Yes ❑ No Grout Seal ❑ No ❑ Yes _ _ _._ ft below ground surface (bgs) Hole Diameter inches Well Conductor Casing ❑ Yes ❑ No Depth of Conductor Casing ft bgs Diameter of Conductor Casing inches Well Casing Diameter__ inches Total Depth _1C2' _ It Depth to Water,__ ft Depth of Casing - _ _. ft bgs DESTRUCTION SPECIFICATION Sealing Material from ft bgs to I J� ft bgs Filler Material_ 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 ❑ Explosives ❑ Detonating cord ❑ with projectiles every ft ❑ without projectile ❑ Detonating cord and boosters ❑ with projectiles every ft ❑ without projectile ❑ Other Sealing Material Neat Cement (94 Ib bag/5-6 gal water) Sand Cement sack mix/1 gal water Bentonite Pellets >< Bentonite (20% solids) Manufacturer 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 -CLL 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. MIN U/M V HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS CONTRACTORS SIGNATURE TITLE �/ �J-7G ltd- DATE 2- ,0- Z —2-1 PE Codes 1 DEPARTMENT USE ONLY Check#/ Cash Application Accepted By Date Date Area Destruction Inspection By `c •Svc,` Au,q_ Date } (� ��t' i Employee ID# COMMENTS -9,n, "; �.+--+��r* r S , / PE Codes 1 SC Info Received B Check#/ Cash Amount Remitted Date PermiU Service Re uest # _ Invoice # Well ID# 1-1373 ►�� v I�r� S E 8 /t �, ,��}{. I I I (��(�/� WELL DESTRUCION PERMIT 4/30/1230/12 T CA