Laserfiche WebLink
WELL DESTRUCTION PERMIT <br /> wC 1 t *#3 PUBLIC WATER SYSTEM ❑YesyNo <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPT 1868 East Hazelton Avenue-STOCKTON CA 95205-6232 -(209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL(209)953-7697 FOR INSPECT[,. EXPIRES 1 YEAR FROM DATE ISSUED <br /> \ <br /> JOB ADDRESS a C_v_4' Ws nt CITY/ZIP Mra,cy 4S517 <br /> CROSS STREET WDA ILL "-G <br /> fol`% W_o_Nk"N IS 10.5 0 3 1 PARCEL SIZEI-VJ LAN USE APPLICATION# <br /> OWNER 1.} PHONE e 3 5-0("10 V c- <br /> OWNER ADDRESS O CITY/STATE/ZIP <br /> CONTRACTOR PHONE VB 5 <br /> CONTRACTOR ADDRESSL-9LA4 KA CITY/STATEIZIP �J <br /> Irk- <br /> C-57 WELL DRILLING LICENSE NUMBERCLn EXPIRATION DATE <br /> PERFORATION CONTRACTOR PHONE <br /> PERRFOORAT10N CONTRACTOR ADDRESS CITY/STATEIZIP <br /> X/� C-57 Well Drilling a License Number 2—CLQ I Expiration Date � <br /> (ff ��` Bureau of Alcohol,Tobacco and Firearms-Users of High Explosives License Number Expiration Date <br /> CHP Hazardous Material Transportation for Explosives License Number Expiration Date <br /> San Joaquin County Sheriff-Coroner Explosives Application and Permit License Number Expiration Date <br /> Califomia Occupational Safety Health-Blaster License Number Expiration Date <br /> REASON FOR DESTRUCTION ❑ Dry ❑ Replacement Well ❑ Caved In ❑ Pit Well 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 CQNSTRUcnoNT LS ❑ Open Bottom Gravel Pack ElUncased El Other <br /> Well Log copy attached ❑ Yes No Grout Seal ❑ No ❑ Yes It below ground surface(bgs) Hole Diameter inches <br /> Well Conductor Casing❑ Yes ❑ No Depth of Conductor Casing ft bgp Diameter of Conductor Casing inches <br /> Well Casing Diameter_\Q_inches Total Depth.,��ft Depth to Water ft Depth of Casing_��Lft bgs <br /> DESTRI-CF10',SPE('IFI(-.A'TION <br /> Sealing Material from It bgs to 212 ft bgs Filler Material from ft bgs to ft bgs <br /> Well casing to be perforated by one of the following m th from ft bgs to It bgs <br /> ❑ Mills Knife _ Number of i ryft and/or <br /> ❑ Explosives❑ Detonati g ecrrt ❑ with projectiles every ft ❑ without projectile <br /> ❑ ating cord and boosters ❑ with projectiles every ft ❑ without projectile <br /> ❑ Other <br /> Sealing Material Neat Cement(94 Ib bag/5-6 gal water) Sand Cement No.. _sack mix/7 gal water Bentonite Pellets <br /> Bentonite(20%solids) Manufacturer Spec%solids_% Name Specs on File Specs Submitted <br /> Placement Method /X Pumped Free Fall Other <br /> Seal Completion Corrlplete with Mushroom Cap 9.0 ft 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 /> MINIMUM 24 HOUR ADVANCE NOTICE REQUIP ECTIONS <br /> CONTRACTORS SIGNATUREVLZL TITL V 1 DATE--LM26- I <br /> I <br /> T <br /> _.i - ,;-FN oqQ� 21 <br /> vz sol. <br /> PA TMENT USE ONL NDFpq��Tq��' <br /> Application Accepted By Date Z Area MFNT <br /> Destruction Inspection By— Date Employee ID <br /> COMMENTS d O J <br /> f <br /> PE SC Received hec Amount Date Permit/ Invoice# Well ID# <br /> Codes Info By Cash Remitted Service Request# <br /> EHD 43-08 WELL DESTRUCTION PERMIT <br /> 10/5107 <br />