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I <br /> Tr <br /> WELL DESTRUCTION PERMIT <br /> PUBLIC WATER SYSTEM ❑Yes ❑Nt <br /> SAN JOAQUIN COUNTY ENYIR011ill HEALTH DEPARTMENT 1868 East Haaelton Avenue-STOCKTON CA 95205.(209)4683420 <br /> NON-REFUNDABLE PERMIT CALL 309 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM GATE ISSUED <br /> cmrnP ��y I'll'1 1111111 r c Gr" <br /> lip <br /> JOB ADDRESS PARCEL SIZE R av L�AA4p USE�APPP/LICATION E <br /> APN lq IIS �� PHONE 'l �a0� <br /> CROSS STREET ^^ 1 Z�� O r <br /> OWNER 1 f <br /> G G I`I CmBTATE �tmyyP I� <br /> OWNER ADDRES'(S�(� �a r PHONE �/' L. <br /> 611 v <br /> CONTRACTOR 1 r V <br /> CITY/STATEMP <br /> CONTRACTOR ADDRESS 19�.-,O „ }�. <br /> C-57 WELL DRILLING LICENSE NUMBER <br /> EXPIRATION DATE Ir t ✓� rVY <br /> PHONE <br /> PERFORATION CONTRACTOR CITYISTATEMP <br /> PERFORATION CONTRACTOR ADORE 55 License Number Expiration Date <br /> ❑ C-57 Well Drilling Expiration Date <br /> ❑ Bureau of Alcohd,Tobacco and Firearms•Users of High Explosives License Number P Ex iration Date <br /> License Number <br /> ❑ CHP Hazardous Material Transportation for Explosives Expiration Date <br /> ❑ San Joaquin County Shedtf•Comner Explosives Application and Permit License Number E xoratim Date <br /> ❑ California Occupational Safety Health-Blaster <br /> License Number <br /> REASON FOR DESTRUCTION Dry ❑ Replacement Well ❑ Caved In ❑ Pit Well ❑ Inactive ❑ Test Hole <br /> DetectediSuspected Well We 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 ❑ Other _ <br /> Well Log copy attached ❑ Yes ❑ No Grout Seal ❑ No ❑ Yes_ it below ground surface(bgs) Hole Diameter inches <br /> Well Conductor Casing❑ s ❑ fJ0 Depth of Conduct Casing _ft s Diameter of Conductor Casing inches <br /> Well Casing Diametet�inches Total Depth M It Depth to Water It Depth of Casing _it bgs <br /> DESTRUCTION SPECIFICATION <br /> Sealing Material from it bgs to J-L..it bgs Filler Material from it bgs to it bgs <br /> Well casing to be perforated by one of the following methods: from it bgs to —it bgs <br /> ❑ Mills Knife Number of cuts every ft and/or <br /> ❑ Explosives❑ Detonating cord ❑ with projectiles every ft ❑ without projectile <br /> ❑ Detonating cord and boosters ❑ with projectiles every H ❑ without projectile <br /> ❑ Omer <br /> Sealing Material ! Neat Cement(94 Ib bagr5-6 gal water) Sand Cement sack miw7 gal water Bentonite Pellets <br /> Bentonite(20%solids) a Manufacturer Spec%solids_% Name_,._________ Specs on File Specs Submitted <br /> Placement Method -, Pumped il Free Fall Other <br /> Seal Completion Complete with Mushroom Cap it bgs Complete to Existing Surface Pad <br /> I HEREBY CERTIFY THAT I 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 I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> 99 <br /> MINIMUM XHOUR ADVANCE NOTICE REQUIRED <br /> ,FOR <br /> �INSPECTIONS <br /> CONTRACTORS SIGNATURE TITLE�Y I lwl �J `DATE O V1� <br /> I `/' <br /> 1 <br /> - - - - -- - - . CEIVED <br /> _. - <br /> - R <br /> 04 2021 <br /> QUIN COUNTY <br /> N 119 <br /> VONMIENTAL <br /> kL FH DEPARTMENT <br /> 4-14 <br /> EP, TMENT USE ON <br /> Application Accepted By —_ Date !^'/ "� Area <br /> Destruction Inspection By - Date f� LI Employee IDN <br /> COMMENTSJAMI 1 at <br /> PE SC Received Checks/ Amount Permit/ <br /> Code 1 o B Stillemitted Date Service Request 0 Invoice a Well IDs <br /> ed Z► lI <br /> E H I D 4308 L <br /> 4 f ZT 35 3,5-- WELL DESTRUCTION PERMIT <br />