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WELL DESTRUCTION PERMIT PUBLIC WATER SYSTEM []Yes El No SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 600 E MAIN STREET - STOCKTON CA 95202 - (209) 468-3420 NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS 2# At, • i if cirdzip • CROSS ST7ET APN PAL SIZE i$ ) I LAND USE APPLICATION # OWNER\ )CatkIV) I . roe i_ve94 -- /78-/flikt PHONE rpt)/q"' 1-7 D-- 4--I'2--) OWNER ADDRESS 5--Cc)-0 75 irOif,/ ildk CITY/STATE/ZIP /100:114164 902./7 CONTRACTOR Pnieg45 bt alla- f '''.."/ i PHONE 2D,q-q31- OID CONTRACTOR ADDRESS 212-0 a) 1 July V CITY/STATE/ZIP ..locivi-i-n rp. (..?,,v,c- 0..,,' C-57 WELL DRILLING LICENSE NUMBER k;lc?(V10 EXPIRATION DATE /-N- (-9.,--,7 PERFORATION CONTRACTOR PHONE PERFORATION CONTRACTOR ADDRESS CITY/STATE/ZIP El C-57 Well Drilling License Number Expiration Date 0 Bureau of Alcohol, Tobacco and Firearms - Users of High Explosives License Number Expiration Date 0 CHP Hazardous Material Transportation for Explosives License Number Expiration Date 0 San Joaquin County Sheriff-Coroner Explosives Application and Permit License Number Expiration Date 0 California Occupational Safety Health - Blaster License Number Expiration Date REASON FOR DESTRUCTION D Dry 0 Replacement Well 0 Caved In 0 Pit Well 114c Inactive 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 El Open Bottom 0 Gravel Pack 0 Uncased 12 Other Well Log copy attached 0 Yes No Grout Seal 0 No 0 Yes ft below ground surface (bgs) Hole Diameter inches Well Conductor Casing 0 Yes No Depth of Conductor Casing ft bgs , Diameter of Conductor Casing inches / rf Well Casing Diameter to inches Total Depth -ig p ft Depth to Water_27 (0 %Leal Depth of Casing ft bgs DESTRUCTION SPECIFICATION Sealing Material fromVO1tA.1, ft bgs to i 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 0 Mills Knife Number of cuts every ft and/or CI Explosives 0 Detonating cord 0 with projectiles every ft El 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) -I Sand Cement sack mix/7 gal water A Bentonite Pellets Bentonite (20% solids) : Manufacturer Spec % solids % Name - Specs on File Specs Submitted Placement Method E Pumped Free Fall.,E3orTrit-i ue• - Other Seal Completion El Complete with Mushroom Cap — ; /3 ft bgs C 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. CONTRACTORS SIGNATURE DVANCE NOTICE REQUIRED FOR INSPECTIONS TITLE /911-7Z04_ DATE 5/0;/)/Z PAY fifEN -Cep, r vet) AlAr n u 2021 tAIV/ QUIN C OUN - • t .22-7-Pk DEPARTMENT USE ONLY , Date Destruction Inspection By Date iii, 4...,, Clik CP ., Date S Jiz./--ao-LA COMMENTS De.1.-;1l'1 frnk )1:5,4 r r-4 t- f i e^/1 e" y t' i 1,71 ) t n 10 ite;t /Orel it' .S.,-('I / C11-- 6, . ,- t -0 -so-.- ,N,-- v.> ..5z -c-,..)._. T-5 \ -{--, ' . v---- --..-,----0 I ..--.,.. ,C'k N -1---'S- •,--- C- leVc--9,5 N. j \ ._A iD.-.<2:51acv-N C-erR • S'n t--- PE SC Received (Check 'Amount Date Permit/ Invoice # Well ID# Codes Info ash Remitted Service Request # ' - - -13 IC- i B6 0,6 f((2,0(42,-/ 4:11 .1Q-21 V/P°OLIZOW EHD 43-08 WELL DESTRUCTION PERMIT :SSMIOCIV TLIS Application Accepted By Area //q Employee ID# 10/5/07