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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 CAL,/L 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED &?/,gJOB ADDRESS �,+ y �jQ/�S L R! CITY/ZIP �PnC h ��JiO %,,-Z3 f CROSS STREET � 07M�� APN lq3 226> -314,' PARCEL SIZE �HLANN�D USE � j _ APPLICATION# OWNER PHONE Zt `LIrZO OWNER ADDRESS / CITY/STATE/ZIP 533 7 CONTRACTOR ;F-3,.-77-5-7 ycrr^ �/L L i/t{ /I/(i PHONE 7 7 Z Z 7—j 7 CONTRACTOR ADDRESS QQ /4�>4X f 3 Z',� CITY/STATE/ZIP 4&L4(fie' 607 0/'.45 Go 9.'TZ S'Z X C-57 WELL DRILLING LICENSE NUMBER le9l 707 EXPIRATION DATE PERFORATION CONTRACTOR PHONE PERFORATION CONTRACTOR ADDRESS CITY/STATE/ZIP X 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 ❑ Yes ❑ No Grout Seal ❑ No ❑ Yes It below ground surface(bgs) Hole Diameter _ inches Well Conductor Casing ❑ Yes ❑ No Depth of Conducting____ ft bgs Diameter of Conductor Casing _ inches Well Casing Diameter-— inches Total Depth Y Z ft Depth to Water__It Depth of Casing _ It bgs DESTRUCTION SPECIFICATION T Sealing Material 4orn 17 It bgs to ft bgs Filler Material_ /•4 /GC�from ft bgs to ft bgs Well casing to be perforated by one of the following methods: _- _from_ _ ft bgs to___ ft bgs ❑ Mills Knife Number of cuts every _ __ It and/or ❑ Explosives ❑ Detonating cord ❑ with projectiles every ft ❑ without projectile ❑ Detonating cord and boosters ❑ with projectiles every ft ❑ 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 ?p V11",os _ Specs on File Specs Submitted Placement Method Pumped X Free Fall Other Seal Completion )4Complete 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. MINIMU HOUR AD E NOTICE REQUIRED FOR INSPECTIONS CONTRACTORS SIGNATURE 7 TITLE�O DATE i i I 3 , _....._._. t_- ..----•-----......................_...._._._...__.....-.._------ ------ L_ __ ..___._. _.____.___.._ _........._..e_....__.....---_....__. ._. _._........_....__..........__........_._......---.,_.._.4.__._ __...__.._.._......_ ....._......_....._.__ w...- i I I I _. __._._____._......................._.--........._....._........._._... ................ _._...... .. .......-'i .. _... _ _... __ ... .._ ... _.. ............ — i log ...........---.. ..... . ._.- - _- .. _ ......_. .m.-. _. .__... __ _ _ 4: ?SANS EN QAct�lr1 CO � I N N, fE U I E'4CT E AR� � PARTMENT USE ONLY Iq 9 7 g Application Accepted By _ Date `�`� Area ` Destruction Inspection By Date / )I 1-2—o _l Employee ID COMMENTS w tela e fm1 on G d R d i v5l 3/T/ vie II t*p t ) PE SC Received, heck#/ Amount D to Permit/ Invoice# Well IN Codes Info B s Remitted Service Re est# EHD 43-08 WELL DESTRUCTION PERMIT 4/30/12