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11,f3 <br />MI UM OUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS ...„Z__ <br />CONTRACTORS SIGNATURE TITLE "0/-"I`° 46rn.---- DATE 6 z / <br />PAymENT <br />REttIVED <br />MAY 0 6_2021 <br />SAN-JOAQUIN'COLIN'Y ENVIRONMENTAL <br />HEALTH DEPA'RTMNT <br />irtA`34a) <br />Dr 4't <br />11e4A6- <br />Lç <br />D .E ARTMENT USE ON <br />Date <br />Date <br />\r,.j e US--c C_ <br />Application Accepted By <br />Destruction Inspection By <br />COMMENTS \)Q <br />„cop-) s•-•-s- <br />WELL DESTRUCTION PERMIT <br />PUBLIC WATER SYSTEM LI Yes Ej No <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />1868 East Hazelton Avenue - STOCKTON CA 95205 - (209)468-3420 <br />NON-REFUNDABLE PERMIT <br /> CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM D <br />JOB ADDRESS lo 5 0 T%-*-leuctet/ Prilte..-- CITY/ZIP Z. 6r4.4 1 SLCt 2- <br />CROSS STREET P1 ; I Is APN / )21— qo - 06 PARCEL SIZE 0 glIAND USE APPLICATION # , <br />i OWNER GP 6._-r-Lo 1.1/1441 .-u- PHONE / <br />OWNER ADDRESS 1 7 1/ , 1-,7 (A,e, v-A--kenrclit- 6_7-- CITY/STATE/ZIP (....4-742t <br />CONTRACTOR /Zee r Ylt• o' /055- I,,..),,g 4 —I-- P4-474_ PHONE <br />CONTRACTOR ADDRESS , • 6 )& 1 6 CITY/STATE/ZIP 247r../1 . /4 9 5" 2 / <br />C5g.- C-57 WELL DRILLING LICENSE NUMBER .67 / 0 3 EXPIRATION DATE 2 <br />PERFORATION CONTRACTOR PHONE <br />PERFORATION CONTRACTOR ADDRESS CITY/STATE/ZIP <br />0 C-57 Well Drilling License Number Expiration Date <br />0 Bureau of Alcohol, Tobacco and Firearms - Users of High Explosives License Number Expiration Date <br />0 CHP Hazardous Material Transportation for Explosives License Number Expiration Date <br />0 San Joaquin County Sheriff-Coroner Explosives Application and Permit License Number Expiration Date <br />0 California Occupational Safety Health - Blaster License Number Expiration Date <br />REASON FOR DESTRUCTION 0 Dry 0 Replacement Well 0 Caved In 0 Pit Well active 0 Test Hole <br />Detected/Suspected Well Water Contaminant(s) <br />Adjacent property with contamination (Address) <br />Known Soil/Water contaminants at adjacent property <br />EXISTING WELL CONSTRUCTION DETAILS X., Open Bottom 0 Gravel Pack 0 Uncased 0 Other <br />Well Log copy attached 0 Yes 0 No Grout Seal 0 No 0 Yes ft below ground surface (bgs) Hole Diameter inches <br />Well Conductor Casing 0 Yes 0 No Depth of Conductor Casing _ft bgs Diameter of Conductor Casing inches <br />Well Casing Diameter 1 inches Total Depth /ZitI,_ ft Depth to Water 5-7 ft Depth of Casing ft bgs <br />DESTRUCTION SPECIFICATION <br />Sealing Material from ft bgs to ft bp Filler Material 4.,....e.4._ from 3 ft bgs to /1.-D ft bgs <br />Well casing to be perforated by one of the following methods: from ft bgs to ft bgs <br />0 Mills Knife Number of cuts every ft and/or _ <br />0 Explosives 0 Detonating cord 0 with projectiles every ft 0 without projectile <br /> <br />0 Detonating cord and boosters 0 with projectiles every ft 0 without projectile <br />0 Other <br />Sealing Material Neat Cement (94 lb bag/5-6 gal water) Sand Cement t 0.. 5 sack mix/7 gal water 0 IL Y Bentonite Pellets ‘,. <br />Bentonite (20% solids) Manufacturer Spec % solids r',,, Name Specs on File Specs Submitted <br />Placement Method Pumped Free Fall Other <br />Seal Completion Complete with Mushroom Cap ft bgs to Existing Surface Pad 2 Complete <br />I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br />JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br />CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br />WORKERS COMPENSATION LAWS. <br />Area 1-1-1 IA-V9 <br />Employee ID# <br />, <br />‘C.5 (K.1 rn. • <br />PE <br />Codes <br />SC <br />Info <br />Received <br />, By ,-- <br />theck#/ <br />Cash <br />Amount <br />pemittett, 1 Daje Permit/ <br />Service Request # Invoice # Well ID# <br />ll'i kff vi.74,2 16_;11.c (ei-i Rpocq-ocici <br />EHD 43-08 WELL DESTRUCTION PERMIT <br />4/30/12