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WELL DESTRUCTION PERMIT PUBLIC WATER SYSTEM ❑ Yes ❑ No SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 East Hazelton Avenue - STOCKTON CA 95205 - (209) 468-3420 NON-REFUNDABLE PERMIT CALL (209) 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS Z 5,*37 5 D -n... I-V S4 -C- 1 u�''11 Y /� CITY/ZIP I/OD (gl � T Received CROSS STR/EETT� APN 05?- d �V � D� PARCEL SIZE � �ILAND USE APPLICATION # Dat / OWNER �` 4J�C a �d�� PHONE Well ID# OWNER ADDRESS CITY/STATE/ZIP B CONTRACTOR p (�'D ('r655 ('Jct(b r-� l[� PHONE 2o1 - 1 ?_7 - St 20 CONTRACTOR ADDRESS / o - 4. , 16 cc CITY/STATE2IP � 61 -57 WELL DRILLING LICENSE NUMBER �t(� I Z� EXPIRATION DATE PERFORATION CONTRACTOR PHONE PERFORATION CONTRACTOR ADDRESS CITY/STATE/ZIP ❑ 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 ❑ Inactive ❑ 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 Pack ❑ Uncased ❑ Other _ Well Log copy attached 11 Yes No Grout Seal ElNo ❑ 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_ C/. S inches Total Depth _ 3 It Depth to Water _ —ft Depth of Casing It bgs DESTRUCTION SPECIFICATION Sealing Material from 3 It bgs to �3 0 ft bgs Filler Material 10.$ _ from ft bgs to ft bgs Well casing to be perforated by one of the following methods: from _ ft bgs to it bgs ❑ Mills Knife Number of Cuts every _ ____ft and/or ❑ Explosives ❑ Detonating cord ❑ with projectiles every ft ❑ without projectile ❑ Detonating cord and boosters ❑ with projectiles every It ❑ without projectile ❑ Other Sealing Material Neat Cement (94 lb bag/5-6 gal water) Sand Cement sack mix17 gal water Bentonite Pellets Bentonite (20% solids) Manufacturer Spec % solids - % Name Specs on File Specs Submitted Placement Method Pumped Free Fall F_ 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. y� M IMUM )d HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS CONTRACTORS SIGNATURE /0� TITLE ar�,-�.G�� DATE - Z E P A R T M ENT USE O N Y Application Accepted By Date Area Destruction Inspection By Date h Employee ID#AZ COMMENTS PE SC Received Check#/ Amount Dat Permit/ Invoice # Well ID# Codes Info B Cash Remitted S ,vice R ue t # K S E H D 43-08 (� "^/ , I r cJ t 7.WELL DESTRUCTION PERMIT 4/30/12 237 i1i