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WELL DESTRUCTION PERMIT PUBLIC WATER SYSTEM ❑Yes ❑No SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPT 1868 East Hazelton Avenue-STOCKTON CA 95205-6232-(209)4683420 NON-REFUNDABLE PERMIT CP LL 20:1 953-7597 FOR INSPECTIONS EXPIRES'I YEAR FROM DATE ISSUED JOB ADDRESS TL Aq CITY2IP CROSS STR'EEETT, ,,_w APN fM� 1W—O PARCEL SIZE(7I.`'A Ir D USE�AJPPPLICATIOONN.#,Y� E OWNER +� ��V•\_ �C t� PHONE OWNERADDRESS n�� D1�0�7� Dq"-QL CITYISTATEI/Z_IPP a CONTRACTOR Q��L}�7Q(L ( ��., �.+�� PHONE VJ`� • Q CONTRACTOR ADDRESS ��M./I�F1GJ/I_ �7 CITY/STATE/ZIP Q C-57 WELL DRILLING LICENSE NUMBER ExPIRATION DATE �O PERFORATION CONTRACTOR PHONE PERFORATION CONTRACTOR ADDRESS CITY/STATERIP ❑ 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 nactive ❑ 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 Peck ❑ Uncased ❑ Other Well Log copy attached ❑ YesNo Grout Seal ❑ No ❑ Yes _It 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.__inches Total DepthV _ _)Depth to Water aDepth of CasingVUk.w"bgs DESTRUCTION SPECIFICATION Sealing Material from ftbgs to bgs Filler Materlal 104 �k from it bgs to%#Vj bgs Well casing to be perforated by one of the following methods: fJJA from ft bgs to ft bgs ❑ Mills Knife Number of cuts every ft anc?/or _ ❑ Explosives❑ Detonating cord ❑ With projectiles every R ❑ without projectile ❑ Detonating cord and boosters ❑ with projectiles every it ❑ without projectile ❑ Other Sealing Material Neat Ceme (941b bag/5-6 gal water) Sand Cement sack mix/7 gal water Bentonite Pellets Bentonite(20 Manufacturerec Y.solids % Name Specs on File Specs Submitted Placement Method ?dM-pe` (l tl IGFree Fall Other Seal Completion Complete wn us room Cap R bgs Complete to Existing Surface Pad I 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. lli' H UR ADVANCE NOTICE REQUIRED FOR INSPECTIONS CONTRACTORS SIGNATURE v TITLE DATE at2z �� r - � + -�--;--r• --- --__..._ice._:—.i. I- i -,—z — -- � � `v 0 21 Qtjllv ' ---;-T co,NT `_ __ FPgRTA L )' _ I ----I— I s — j—�--� ' --i--� S—'r-— — — — DEPARTMENT USE ONll,Y Application Accepted ByL' Dateald I Arae_ Destruction Inspection By Oate Z-- Employee IDM COMMENTS ✓t 19' ;i1 l'I `'; 10()' L- .f 'i I hie)I I.S h '• 'Jell aaJ' u, Ir r3, '► f PE SC Received ChecW Amount Dab pa w Invoice# Well IDM Codes Info B ash Remitted Service Re oast M L;jz 'Sat__ If 16i' :_ 12 ) . EHD 43-08 / WELL DESTRUCTION PERMIT revised 4!1418 125 /