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WELL DESTRUCTION PERMIT <br />PUBLIC WATER SYSTEM ❑ YesVo <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE 3"' FL - STOCKTON CA 95202 - (209) 4_68-3420 <br />NON-REFUNDABLE PERMIT CALL (209) 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS. i l CITY/ZIP <br />SC Received <br />CROSS STREET EAST— /I— �N % � � `2 <br />�/� PARCEL SIZE <br />USE APPLICATION # <br />- <br />�,/J� J�yLAND <br />% �t/i2 /`HONE /L/ <br />OWNER HONE <br />r7 <br />OWNER ADDRESS % / CITY/STATE/ZIP <br />` / r <br />CONTRACTOR /� /� HONE <br />-A <br />3/ <br />CONTRACTOR ADDRESS CITY/STATE/ZIP <br />Remitted <br />*2 C-57 WELL DRILLING LICENSE NUMBER EXPIRATIONDATE <br />/ Z - f <br />f <br />PERFORATION CONTRACTOR //eW;4LdV, <br />F�� ✓=�i PHONE044 <br />3 <br />� <br />PERFORATION CONTRACTOR ADDRESS /�/V 1r; CITY/STATE/ZIP-5/ <br />�! <br />❑ C-57 Well Drilling License Number <br />Expiration Date <br />❑ Bureau of Alcohol, Tobacco and Firearms - Users of High Explosives License Number <br />Expiration Date <br />❑ CHP Hazardous Material Transportation for Explosives License Number <br />Expiration Date <br />❑ San Joaquin County Sheriff -Coroner Explosives Application and Permit License Number <br />Expiration Date <br />❑ California Occupational Safety Health - Blaster License Number <br />Expiration Date <br />REASON FOR DESTRUCTION ❑ Dry ❑ Replacement Well ❑ Caved In ❑ Pit Well <br />Inactive ❑ 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 ❑ Open Bottom Gravel Pack ❑ Uncased <br />❑ Other <br />Well Log copy attached ❑ Yes ❑ No Grout Seal ❑ No ❑ Yes ft below ground surface (bgs) Hole Diameter inches <br />Well Conductor Casing ❑ Yes 7 No Depth of Conductor Casing ft bgs Diameter <br />/Lt <br />of Conductor Casing inches <br />Well Casing Diameter inches Total Depth �17-ft Depth to Water <br />Depth of Casing tt bgs <br />DESTRUCTION SPECIFICATION <br />Sealing Material from tt bgs to ft bgs Filler Material <br />from ft bgs to ft bgs <br />Well casing to be perforated by one of the following methods: from ft bgs to <br />ft bgs <br />❑ Mills Knife Number of cuts every tt and / or <br />Explosives ❑ Detonating cord ❑ with projectiles every ft <br />❑ without projectile <br />❑ Detonating cord and boosters ❑ with projectiles every ft <br />❑ without projectile <br />❑ Other <br />Sealing Material ❑ Neat Cement (94 lb hag /5-6 gal water)/ Sand Cement /n �— suck mix / 7 gal water ❑ Bentonite Pellets <br />❑ Bentonite (20% solids) ❑ Manufacturer Spec % solids % Name <br />❑ Specs on File ❑ Specs Submitted <br />Placement Method ❑ Pumped ❑ Free Fall ❑ Other <br />Seal Completion Complete with Mushroom Cap ❑ Complete to Existing Surface Pad <br />I HEREBY CERTIFY THAT 1 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 1 AM IN COMPLIANCE WITH ALL <br />WORKERS COMPENSATION LAWS. <br />Mi��i`6„%i�O��ANC�i���ICE REQUIRED /��IyN�S�PEC"TIONS <br />CONTRACTORS SIGNATURE TITLE '� "" DATE <br />S�J <br />PAYMENT <br />RECEIVED <br />JUN 0 3 2021 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT <br />E P A R T M E N T USE ONLY <br />Application Accepted By Date Area117 <br />Destruction Inspection By Date I Employee ID# <br />COMMENTS <br />PE <br />SC Received <br />Check#/ <br />Amount <br />Permit/ <br />Codes <br />Info <br />Cash <br />Remitted <br />Date <br />Service Re uest # <br />Invoice # <br />Well ID# <br />3 <br />i 5 <br />SJA <br />EHD 43-02-009 Well Destruction Permit <br />1/27/2005 <br />