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R WELL DESTRUCTION PERMIT <br />PUBLIC WATER SYSTEM D Yes Ve <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPT 1868 East Hazelton Avenue - STOCKTON CA 95205-6232 - (209) 468.3420 <br />..._____..-..,. OVIdi'I V-0 ronNl itATG Iccimn <br />NUN-KEFUNDABLE rt:KM1 I 0. <br />/�, C (—,a �- r'' --i—, ... " "'.._. - r ---- -- -t <br />? 6 c <br />JOB ADDRESS Xc S 1 , � 3 W—CITY2IP 1 r0 -Ci S� 7 / <br />CROSS STREET�f f e- N U r AP1N a` l a� _PARCEL SIZECI , LANfD'USE APPLICAT'11O/N # <br />OWNER ; 1 QToQ-Qr[ r'Vi 6- 1ryV0 g'rl'�+..✓ 5 PHONE `-• I J °7.'� a.4O Sf_3S <br />OWNER ADDRESS 1 Se,—'A CITYISTATFIZIP q <br />CONTRACTOR Cn 1 •J -Tilt ,- Ov, ' i 1� N C.� GQ , PHONE � b 7 r 7 1 <br />CONTRACTOR ADDRESS � � S- <' 1 k r O ✓1 dR CITYISTATE/ZIP -'-' � 1 a LK C"- <br />C-57 <br />ox-C-57 WELL DRILLING LICENSE NUMBER t 1 EXPIRATION DATE S -.51 _ a'\ <br />PERFORATION CONTRACTOR PHONE <br />PERFTION CONTRACTOR ADDRESS CITYISTATEIZIP <br />to C-57 Well Drilling License Number Expiration Date <br />Bureau of Alcohol, Tobacco and Firearms - Users of High Explosives License Number Expiration Date <br />CHP Hazardous Material Transportation for Explosives License Number Expiration Date <br />San Joaquin County Sheriff -Coroner Explosives Application and Permit License Number Expiration Date <br />California Occupational Safety Health - Blaster License Number Expiration Date <br />REASON FOR DESTRUCTION ❑ Dry ❑ Replacement Well ❑ Caved Ir ❑ Pit Well ❑ Inactwe ❑ Test Hole <br />Detected r Suspected Well Water Contaminants) <br />Adjacent property with contamination (Address)e o!moi <br />Known Soil i Water contaminants at adjacent property J - - --- — <br />EXISTING WELL CONSTRUCTION DETAILS ❑ Open Bottom ❑ Gravel Pack ❑ Uncased ❑ Other <br />Well Log copy attacned ❑ Yes ❑ No Grout Seal ❑ So ClYes It below ground surface (ogs} Hole Diameter inches <br />Well Conductor Casing ❑ Yes ❑ No Depth of Conductor Casing ft bgs Diameter of Conductor Casing inches <br />Well Casing Diameter L& inches Total Depth 14 <Z1, _ N Depth to Water It Depth of Casing _�O ft bgs <br />I)F,rRI r'Tnrx SPI'CIFR'ATI01 <br />Sealing Material from ► yo ft bgs to a f: bgs Filler Material_ from fl DgS to ft bgs <br />Well casing to be perforated by one of the following methods: from ft bgs to It bgs <br />❑ Mills Knife Number of cuts every ft and I or <br />❑ Exploslves ❑ Detonating cord ❑ with projectiles every _ ft ❑ without projectile <br />❑ Detonating cord and boosters ❑ with projectiles every _ ft ❑ without projectile <br />❑ Other — <br />Sealing atexieF--tel ement (94 lb bag/ 5-6 gal water) Sand Cement ---,sack mix 1 7 gal water Bentonite Pellets <br />Bentonite (20% solids Manufacturer Spec % solids ao % Name �1' "o u l La Li ( Specs on File Specs Submitted <br />Placement Method Pumped Free Fall Other <br />Seal Completion Complete with Mushroom Cap `�, ft bgs Complete to Existing Surface Pad <br />I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION ANU ]NAI Inc VVVKA ".LL o� uvn� In .. .....�.,..•.. ••,....,• <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 1 AM IN COMPLIANCE WITH ALL <br />WORKERS COMPENSATION LAWS. <br />MIN~,48 HAUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br />c <br />c <br />-­=7-,7:-Z,:;--Z-Z' <br />Application Accepted By — <br />Destruction Inspection By ^ <br />COMMENTS (.�i11JP�T)J✓1 <br />DEPARTMENT USE ONLY <br />Date <br />2//(/- ; Area <br />^� <br />�— Dated I f'j Imo_ Employee ID# S <br />PE <br />SC Received Check#/ <br />Amount Date <br />Permit/ Invoice # Well 10# <br />Codes <br />Info Cash <br />Remitted <br />Service Request # <br />EHO 43-09 <br />(/J� (• 1 2—l St, / J (, WELL DESTRUCTION PERMIT <br />revised 414118 <br />