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WELL DESTRUCTION PERMIT WPUBLIC WATER SYSTEM ❑Yes yNo SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPT 1668 East Hazelton Avenue-STOCKTON CA 95205-6232 -((GG(209)468-3420 NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIi. EXPIRES 1 YEAR FROM DATE ISSUED �L r � JOB ADDRESS ��t�A(y�.`/1]r'(��K�/i11s�r,D�' CITY/ZIP 1 Q� CROSS S7REET_,y \r!1 i O.1 CIU' _ PN�.S IO�''0 I PARCEL Sj�t1. LAND USE APPLICATION# OWNER Q W PHONE t,J —<)6 10 -vicircrICL OWNER ADDRESS 0' CITY/STATE/ZIPr� .CA ?j O CONTRACTOR PHONE CONTRACTOR ADDRES51 CITVISTATEIZIP mpgG C-57 WELL DRILLING LICENSE NUMBER EXPIRATION DATE PERFORATION CONTRACTOR PHONE PERFORATION CONTRACTOR ADDRESS CITY/STATEIZIP C-57 Well Drilling License Number Expiration Date -2J 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 O Replacement Well ❑ Caved In ❑ Pit Well V11narfive ❑ Test Hole Detected/Suspected Well Water Contaminants) 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 ❑ YesNo Grout Seal 11No X0Yesft below ground surface(bgs) Hole Diameter inches Well Conductor Casin ❑ Yes- No Depth of Conductor Casing ft bgs Diameter of Conductor Casing inches Well Casing Diameter\� ps inches Total Depth? Depth to Water 1 ft Depth of Casing y' it bgs DESTRL(T10N SPECIFICATION Sealing Material from 0 ft bgs to�_it bgs Filler Material from ft bgs to ft bgs Well casing to be perforated by one of th f Ilowing methods: from ft bgs to it bgs ❑ Mills Knife _ umber of cuts every it and/or ❑ Explosives onabng 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) 71Sand Cement i sack mix/7 gal water Bentonite Pellets Bentonite(20%solids) Manufacturer Spec%solids_% Name Specs on File Specs Submitted Placement Method Pumped Free Fall Other Seal Completion Co lete with Mushroom Cap 5 ft bgs Complete to Existing Surface Pad I HEREBY CERTIFY THAT 1 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. MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED F R I TIONS CONTRACTORS SIGNATURE DATE —7 �7—' I Ht R MINT PA TMENT USE ONL ENORQtj)NCOUN Application Accepted By Date Area 7 CN ]Y Destruction Inspe tion By Date Employee ID# COMMENTS T -gartz:J3 Is PE SC Received Chec ArnountPE SC Received Chec Amount Permit/ Codes Info By Remitted Pate Service Request# Invoice# Well ID# I EHD 43-08 WELL DESTRUCTION PERMIT 1015107