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JOB ADDRESS 2557 -"")V LO-V-4...., S'er-e4/7,421, .14,0 le/4 CITY/ZIP ZOO& . (--72 Y CROSS STRET }4-1.41-1,- .1-4-N— APN 0 :).- FO 71 0 °.----PARCEL SIZE C'Li LAND USE APPLICATION # OWNER itia/ K FL4"r(7- /0 PHONE OWNER ADDRESS /0/ eV ,I7 "11-1 V fr -1 Li do CITY/STATE/ZIP .L:"1-,..)L -10 1 q S-9 ) CI CONTRACTOR 124-.:141 (7 //".6 LA,Lejl ISAT P.A.A.A.14.-- PHONE CONTRACTOR ADDRESS e. 0 . 140.... I b'is ciTy/sTATEizip c__. ,....c, e 111- 'el 2'f / IlgL C-57 WELL DRILLING LICENSE NUMBER i 4 Cs- (2./ EXPIRATION DATE 2.02, Z-- 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 0 CHP Hazardous Material Transportation for Explosives License Number Expiration Date LI 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 jer-.-.Dry 0 Replacement Well 0 Caved In 0 Pit Well ilk-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 CI Open Bottom 0 Gravel Pack 0 Uncased 0 Other _ Well Log copy attached 0 Yes 0 No Grout Seal LI No 0 Yes _ _ ft below ground surface (bgs) Hole Diameter inches Well Conductor Casing O Yes 0 No Depth of Conductor Casing ft bgs Diameter of Conductor Casing inches Well Casing Diameter _ /0 inches Total Depth _ 7.4 0 It Depth to Water '5' 5— ft Depth of Casing ft bgs DESTRUCTION SPECIFICATION Sealing Material from 0 ft bgs to 0 ft bgs Filler Material /0 • 3 4 ""'""tf. 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 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)p< Sand Cement /0 • S sack mix/7gal water Bentonite Pellets Bentonite (20% solids) Manufacturer Spec % solids % Name Specs on File Specs Submitted Placement Method Pumped X Free Fall ..› I' Other Seal Completion 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. ..$141=)UR ADVANCE NOTICE REQUIRED FOR INSPECT NS CONTRACTORS SIGNATURE TITLE /4- DATE - Z.- t-f • MEI: mall 111111111111.1111110 11111111.11111.11111111101111 NI Mir MINN 1111111111111111111 MEM MEE MEM, .041 LIMI PAYM NT REpJIVED JUN t- SAN JOAQUIN CO UN ENVIRONMEN HEALTH DEPARTME WELL DESTRUCTION PERMIT PUBLIC WATER SYSTEM El Yes LI No SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 East HazeIton Avenue - STOCKTON CA 95205 - (209) 468-3420 NON-REFUNDABLE PERMIT CALL 209 953J.97 FOR INSPECTIONS EXPIRES 1 YEAR F DEPARTMENTUSE ONLY 9 Date Q..) /(2.—Di Employee ID# /kJ PI COMMENTS 1/4e I I co.,' !t) Chi !!ri5.1 (H.L 104 tiV:TieS /3Z) f(' c.,(414.0s irea pc( / t (21 W C' T. h r fi • 1, PE Codes SC Info Received V/ #1 v ash Amount Remitted E?te / Permit/ Service Request # Invoice # Well ID# HS7 1-i 4,S— A 113( EHD 43-08 WELL DESTRUCTION PERMIT Application Accepted By Destruction Inspection By Date 0 414 Area 4/30/12