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WELL DESTRUCTION PERMIT PUBLIC WATER SYSTEM ❑ Yes ❑ No SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE 3"" FL - STOCKTON CA 95202 - (209) 468-3420 NnN_RFFIINhARI.R PERMIT CAI .I.r7f191 "A-7697 Fne INcvr••rTi(w, F.XPIRF,S 1 VF.AR FROM DATE. ISSIIF.D I HEREBY CERTItY THAT 1 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 1 AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION LAWS. M UM 24 UR ADVANCE NOTICE REQUIRED FOR INSPECTIONS CONTRACTORS SIGNATURE TITLE r4 J I d, N Y DATE 2 41, al L Gb�TE r �a VV -f P G RF New MAY 12 SAN J0,4 DEPARTMENT USE ONLY Application Accepted By Date �/ �L 12-1 Area Destruction Inspection By Date Employee ID# �a COMMENTSLOOP Y C) �- "10 /7 1 t ) rj 41,100 I tea �� G� O snl� �tA- PE Codes SC Info ON JOB Ai-ia CITY/ZIP tY► '7` -0` '-- W -S Cj457 70 CROSS APN (�'� PARCEL SIZE C* L(An/N-�D USE APPLICATION # OWNE PHONE(/(/ L�C �e I OWNER ADDl j/��.,,^,'L�.y�� CITY/STATE/ZIP "�'^ , v°1 C �s2 i 5 CONTRACTOR PHONE NTTRACTOR ADDRESS nV CO`i C-57 WELL DRILLING LICENSE NUMBER CITY/STATE/ZIP EXPIRATION DATE PERFORATION CONTRACTOR PHONE P FORATION CONTRACTOR ADD E C-57 Well Drilling ❑ B au of Alcohol, Tobacco and Firea - Users of High Explosives CITY/STATE/ZIP License Number Expiration Date License Number Expiration Date ❑ CHP ardous Material Transportation for losives License Number Expiration Date ❑ San Joaquin unty Sheriff -Coroner Explosives ation and Permit License Number Expiration Date ❑ California Occupatt nal 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 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 t Well Casing Diameter i7 inches Total Depth ft Depth to Water_ 66 ft Depth of Casing ft bgs DESTRUCTION SPECIFICATION Sealing Material from ft bgs to 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 /b bag / 5-6 gat water) ❑ Sand Cement suck mix / 7 gal water Bentonite Pellets ❑ Bentonite (20% solids) ❑ Manufacturer Spec % solids % Name ❑ Specs on File ❑ Specs Submitted Placement Method ❑ Pumped A Free Fall ❑ Other Seal Completion Complete with Mushroom Cap ft bgs ❑ Complete to Existing Surface Pad I HEREBY CERTItY THAT 1 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 1 AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION LAWS. M UM 24 UR ADVANCE NOTICE REQUIRED FOR INSPECTIONS CONTRACTORS SIGNATURE TITLE r4 J I d, N Y DATE 2 41, al L Gb�TE r �a VV -f P G RF New MAY 12 SAN J0,4 DEPARTMENT USE ONLY Application Accepted By Date �/ �L 12-1 Area Destruction Inspection By Date Employee ID# �a COMMENTSLOOP Y C) �- "10 /7 1 t ) rj 41,100 I tea �� G� O snl� �tA- PE Codes SC Info Received Check#/ B Amount Remitted Date Permit/ Service Request # Invoice # Well ID# +3-73 1 Cl 5 -1 Z-1 00 EHD 43-02-008 Well Destruction Permit 1/27/2005