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DATE /4 - 3/- 40 • JOB ADDRESS 2. 37 5- zem<m- 6-4e0-0.. ( ciTyiziP 1.0.06 CROSS STREET 241,- APN 4)-8.041 CtOc PARCEL SIZE --` I LAND USE APPLICATION If OWNER 676 te Wel/ Fa i yr s. Li- c PHONE IOU OWNER ADDRESS Jo 30 f i : 1., i -}y P k1 * 1-0() ciTy/sTATErzip f.7-/-i k4.-n eis-,...3,ig CONTRACTOR ,L _:---4. 6P65 Lid....-e4-,- t A-7 PHONE 717 CONTRACTOR ADDRESS , 17 . 145 ".-- A $ CITY/STATE/ZIP Attil .Ail ,5 aliv/ bd. C-57 WELL DRILLING LICENSE NUMBER if' S /2. EXPIRATION DATE 2 • zsli- PERFORATION CONTRACTOR PHONE PERFORATION CONTRACTOR ADDRESS CITY/STATE/ZIP 0 C-57 Well Drilling License Number Expiration Date 0 Bureau of Alcohol, Tobacco and Firearms - Users of High Explosives License Number Expiration Date El CHP Hazardous Material Transportation for Explosives License Number Expiration Date O San Joaquin County Sheriff-Coroner Explosives Application and Permit License Number Expiration Date CI California Occupational Safety Health - Blaster License Number Expiration Date REASON FOR DESTRUCTION 0 Dry 0 Replacement Well p Caved In El Pit Well active 0 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 0 Gravel Pack El Uncased III Other Well Log copy attached 0 Yes 0 No Grout Seal El No El Yes . ft below ground surface (bgs) Hole Diameter inches Well Conductor Casing 0 Yes El No Depth of Conductor Casing ft bgs Diameter of Conductor Casing inches Well Casing Diameter t inches Total Depth /GeV ft Depth to Water ‘-i4 ft Depth of Casing ft bgs DESTRUCTION SPECIFICATION Sealing Material from 0 ft bgs to /0° ft bgs Filler Material #4017.1e-- from ft bgs to ft bgs Well casing to be perforated by one of the following methods: from ft bgs to ft bg!,; CI Mills Knife _ Number of cuts every ft and/or 0 Explosives 0 Detonating cord 0 with projectiles every ft 0 without projectile 0 Detonating cord and boosters 0 with projectiles every ft 0 without projectile 0 Other Sealing Material Neat Cement (94 lb bag/5-6 gal water) Sand Cement sack mix/7 gal water be Bentonite Pellets Bentonite (20% solids) Manufacturer Spec % solids_ `)/0 Name Specs on File , Specs Submitted _ Placement Method Pumped m Free Fall Other Seal Completion X Complete with Mushroom Cap .._, ft 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 LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION LAWS. 1i8 .TNIURZ ILIOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS TITLE /lar jf — CONTRACTORS SIGNATURE 0 -yv.D ,SLA j42_,S\--?rc_Fc. G\ .4 - netlie4411" Iv" AYMENI. RECEivit; OE C 3 1 2020 SAN JOAQUIN COUNTY ENVIRONMENTAL BEALrit oinkreTMENT Application Accepted By Destruction Inspection By COMMENTS C3 41/2-x -i/ Area ONL Y /?/...?/%06Z ,C7 DEPARTMENT USE Date Date .C) -1,1->2\ Employee ID# WELL DESTRUCTION PERMIT PUBLIC WATER SYSTEM Yes No SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 East HazeIton Avenue - STocKToN CA 95205 - (209)468-3420 NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED PE Codes SC Info Received By Check#/ Cash Amount Remitted 4Da e I Permit/ Service Request If Invoice If Well ID# 113-7 3 H., i V On— WIS.- kl?CCA-152.3 EHD 43-08 4/30/12 WELL DESTRUCTION PERMIT