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WELL DESTRUCTION PERMIT PUBLIC WATER SYSTEM ❑ Yes ❑ No SAN JOAOUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 East Hazelton Avenue - STOCKTON CA 95205 - (209) 468-3420 NON-REFUNDARLE PERMIT CALL (9091 953-7697 FnR IN(;PFrTIONC FXPIRFS 1 VFAP Fanm nATF Iccrrr=n Cl Received Check#/ JOB ADDRESS _I , P I r) Q ze7wI CITY/ZIP C ( —C-. / L CROSS STREET W y APN (7 ` O '7PARCEL SIZE LAND USE APPLICATION # OWNER :) \ t ki- ^ PHONE Codes Info OWNER ADDRESS /,• S S CITY/STATE/ZIP Remitted CONTRACTOR PHONE Service Request # /e/ ` CONTRACTOR ADDRESS _ (�J . ems' 1 d CITY/STATE21P 7 �j 7 (,ODATE-7-47,7- kY C-57 WELL DRILLING LICENSE NUMBER �l 3 EXPIRATION DATE 7 -47,7 - PERFORATION 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 ❑ 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 0- Open Bottom ❑ Gravel Pack ❑ Uncased ❑ Other _ Well Log copy attached ❑ Yes ❑ No Grout Seal ❑ No ❑ Yes If 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_ / Z__ _ inches Total Depth J Z,v ft Depth to Water 14O It Depth of Casing _.. ft bgs DESTRUCTION SPECIFICATION Sealing Material from 0 ft bgs to ft bgs Filler Material —_— from _ ft bgs to __ft bgs Wellsing to be perforated by one of the following methods: —_—_from _ ft bgs to ft bgs f9�[Jlills Knife f Number of cuts every ?Lft 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 lb bag/5-6 gal water) I Sand Cement — sack mixll gal water Bentonite Pellets Bentonite (20% solids) Manufacturer Spec % solids % Name Specs on File Specs Submitted Placement Method Pumped Free Fall -1 Other Seal Completion Complete with Mushroom Cap % ft bgs I i 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. MIN UM HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS CONTRACTORS SIGNATURE /1�G///TITLE Ga!�d� DATE , DF-- �Fj�MENT Application Accepted By _ Destruction Inspection By Area lqci v PE Sc Received Check#/ AmountPermit/ Date Invoice # t` 1 # Codes Info B Cash Remitted Service Request # 7 -- -- -- - - — HEALT -- ONM-NT NTY' EHD 43-08 WELLDEST�I i4RMl1 4/30/12 ( :'41�b%r