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WELL DESTRUCTION PERMIT '''��//� we` ` ,►-{� PUBLIC WATER SYSTEM ❑ Yeso SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPT 1 �"�'" 1868 East Hazelton Avenue - STOCKTON CA 95205-6232 - (209) 468-3420 Nr)N_QGFIINn ARI c Pr QUIT rAl i 19I191 9K3-i6q7 FnR IIJRPFCTInNS FXPIRFS 1 YFAR FRou DATF ISSlIFT1 JOB ADDRESS I 1 5 \ / \ . CITYIZIP O` / CROSS STREET0 �[_( d.� PN O PARCEL SIZE-2miF?LAJN'D& # �( _1APPLICATION OWNER O PHONE CIL OWNER ADDRESS% CITY/STATE/ZIP �Q A CONTRACTOR1 T PHONE 1 CONTRACTOR ADDRESS{ I.� Q CITY/STATE21P Qfr•l b 15 Q C-57 WELL DRILLING LICENSE NUMBER—L cQ ^ EXPIRATION DATE PERFORATION CONTRACTOR PHONE PERFORATION CONTRACTOR ADDRESS CITY/STATE/Z PP C-57 Well Drilling zOO License Number -1 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 YL Detected / Suspected Well Water Contaminant(s) Adjacent property with contamination (Address) Known Soil / Water contaminants at adjacent property EXISTING WELL CONSTRUCTION DET ❑ Open Bottom Gravel Peck ❑ Uncased ❑ Other Well Log copy attached ❑ Yes No Grout Seal ❑ No ❑ Yes ft below ground surface (bgs) Hole Diameter inches Conductor Well Conductor Casing ❑ Yes ❑ No Depth of Conductor axing _ ft bgs Diameter of Conductor Casing inches p. Well Casing Diameter—A-0--inches Total Depth Depth to Water Ft ft Depth of Casing:, It bgs DESTRLCTION SPECIFI(�ATH111 Q 2-115 Sealing Material from ft bgs to ft bgs Filler Material from ft bgs to ft bgs Well casing to be perforated by one of the following methods: from ft bgs to ft bgs nth ❑ Mills Knife Number of cuts e�Owith ❑ Explosives ❑ Detonating cord th projectiles every ft ❑ Without projectile tOoalin and boosterprojectiles every ft ❑ without projectile ❑ Other Sealing Material Neat Cement (94 Ib bag/ 5-6 gal water) K Sand Cement 1 Q • !1 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 Complete with Mushroom Cap S 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. 1 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. I 1 / PA ITMENT USE O L SAN✓Q , 4U`1 Application Accepted By ' Date Area EAn..AQ(l/N L.OU Destruction Inspections yy Date Employee ID# �� ,1,M, "i COMMENTS AA21 41`r—< A,,n �,//�1?Za'�_1A / ZlWT PLLrJy� LL._ PE Sc Received Check#/ Amount DatePermit/ Invoice # Well ID# Codes Info B Remitted Service Re uest # p 2 — i EHD 43-08 WELL DESTRUCTION PERMIT 10/5/07