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geGo' 24 tkauN tso stm \go e.1, iv\ Qv '1 /4AEP- Application Accepted By Destruction Inspection By COMMENTS DEP RTMENT USE 041. Date Date WELL DESTRUCTION PERMIT PUBuC WATER SYSTEM D Yes EI No SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPT 1888 East Hazelton Avenue - STOCKTON CA 95205-6232 - (209)468-3420 NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED , . JOB ADDRESS 1 5 d1 5 o I;) rcinc\ A- 1K 17 cinizip L ci c), I r • CROSS STREET N . TIM 1 1Z, 7 APN 0 --)3 100 ,-)17 i PARCEL sizel G LAND USE APPLICATION # OWNER 1\1\ , V, iC... C S- 1 CI trl CI PHONE CA (-1 - C) <- OWNER ADDRESS , _..." i-A i's1 e CITY/STATE/ZIP , CONTRACTOR \,1 <111 t. i C;\ C ` \\ \ n) PHONE ;201 34.1 61 - R7 7 cl, CONTRACTOR ADDRESS ? iC) • 13 0 4 cm/sun/zip Gel 11,_i c A ci s c, 3 '.? .I, "").. C-57 WELL DRILLING LICENSE NUMBER 67cl 9 3 S -2:3 EXPIRATION DATE —7 - 3 I - PERFORATION CONTRACTOR PHONE PERFORATION CONTRACTOR ADDRESS CITY/STATE/ZIP ID 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 0 Dry 0 Replacement Well 0 Caved In 0 Pit Well 3g. 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 )gt Open Bottom 0 Gravel Pack 0 Uncased 0 Other Well Log copy attached 0 Yes la No Grout Seal 0 No kt, Yes 50 ft below ground surface (bgs) Hole Diameter 1 inchee Well Conductor Casing 0 es IA. No Depth of Conductor Casing ft bgs Diameter of Conductor Casing incheil Well Casing Diameter inches Total Depth I ci.30 ft Depth to Water I 0 ft Depth of Casing 4.11_A__ tt Ns DBsTRLCTION SPECIFICATION ..iii i OD I W C C Sealing Material from ,c,11. • .3? ft bgs to j ft bgs Filler Material 1 0 . 3 co, K from *ID ft bgs to -1 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 lot 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/b bag /5-6 gal water) Sand Cement 1C: • 5 sack mix I 7 gal water Bentonite Pellets Bentonite (20% solids) Manufacturer Spec % solids % Name Specs on File Specs Submitted Placement Method )/Pumped Free Fall Other Seal Completion Complete with Mushroom Cap S 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. MINIMUM 48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS CONTRACTORS SIGNATURE 74/1 Care.A•6- TITLE C "C. Prr (16-0:ATE 5) Ic2 V IsrcAn 6 i- g 7 07A :001'11N1 1_ __-- ( i (2C ' ..-..- c., r...72 - , c J VN -) 7C) 1 1.417c .6 Ce ) I 0 ei. ) ..t).(- .,),, Q \pie 1\ PE Code". SC Info Received BT-A Check#/ Amount emitted Date , Permit/ Service Request # Invoice # Well ID# (37b(_w-t- Cash ,i i (idev.er-t- I's- vzgx,,/ titf n a .467 6.41)-4//2„.5-67133 WELL DESTRUCTION PERMIT EHD 43-0B revised 4/14/18