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WELL DESTRUCTION PERMIT PUBUC WATER SYSTEM ❑ Ye—f No SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPT 7868 East Hazelton Avenue - STOCKTON CA 95205-623__2 - \\(209) 468-3420 I..c.....r.— CVOIDCC '1 VCAD i nATC ICCIi ' JOB ADDRESS y - 'e -G J Che ck#/ ash 1CITYZP SIZCE (y^ USE APPLICATION # CROSSSTREET' % T� I APN �V� `�� PARCEL AND PHONE S V — Q - O OWNER 1 R� \ Ai fh 3 OWNER ADDRESS O-ZI,- t^coo CITYISTATEIZIP V q e liq 3 L, CONTRACTOR Q ,Y' I L 11 PHONE bjl� CONTRACTOR ADDRESS S W OcO CrTY/STATEZD uu v C-57 WELL DRILLING LICENSE NUMBER EXPIRATION DATE\ PERFORATION CONTRACTOR PHONE , \ PERFORATION CONTRACTOR ADDRESS W CRYISTATFJLP 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 Shenff-Coroner Explosives Application and Permit License Number Expiration Date California Occupational Safety Health - Blaster License Number Expiration Date REASON FOR DESTRUCTION ❑ Dry ❑ Replacement Well 1KI Caved In ❑ Pit Well ❑ Inactive ❑ Test Hole Detected / Suspected Well Water Contaminant(s) 114 14.1 Adjacent property with contamination (Address) iJ it Known Soil / Water contaminants at adjacent property h1 A _ EXISTING WELL CONSTRUCTION DETAILS ❑ Open Bottom Gravel Pack ❑ UnCaSed ❑ Other _ Well Log copy attached ❑ Yes AR, No Grout Seal A W ❑ Yes It below ground surface (bgs) Hole Diameter tv inches Well Conductor Casing ❑ Yes t1,. No Depth of Conductor Casing�_It bgs Diameter of Conductor Casing � inches Well Casing Diameter_ inches Total Depth 5d ft Depth to Vater 35 h Depth of Casing fl bgs D ESTR1'('T10\ SPF.(CIFICATION Sealing Material from 5 O _ft bgs to . It bgs Filler MaterialT o ry , from ft bgs t ft bgs Well casing to be perforated by one of the following methods: from It bgs to It 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 Seali at Cement (94 Ib bag / 5-6 gal water) Sand Cement sack mix / 7 gal water Bentonite Pellets Bentonite (20% solids Manufacturer Spec % solids_% Name Specs on File Specs Submitted Placem a Io Pumped Free Fall Other Seal Completion Complete with Mushroom Cap It 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 UCENSE BOARD AND THAT I AM IN COMPUANCE WITH ALL WORKERS COMPENSATION LAWS. MIOZ�7 �NOTICE REQUIRED FOR INSPECTIONS CONTRACTORS SIGNATURE plZm+1 TITLE lf� Ot.^'-I� 41DATE ^ 0 —� 1 sgti✓ p� 6 tiFE�yEQCC ti X21 FNT DEPARTMENT USE ONLY Application Accepted By TLDate I Area Destruction Inspection By Date _�A Employee ID# COMMENTS -(I S4 ed FSC 7 1, )y) S I L,%4v Ye 1 i! le -it, c , c O, mac, lC e • n i': Int��rAt c' r4/c } .c j /t3 b VIII reJr.,, PE Codes y3 E SC Received Info B caE o Che ck#/ ash Amount Remitted S -a permit/ Date rvice Request # Invoice # Well ID# 02- EHD 43-08 `/'� G revised 4„4118 �A 11-7 7 7 ! � S WELL DESTRUCTION PERMIT Corm 1N i}JF(S/