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WELL DESTRUCTION PERMIT PUBLIC WATER SYSTEM ❑ Yes No SAN JOAOUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 East Hazelton Avenue - STOCKTON CA 95205 - (209) 4✓`68-3420 NON-REFUNDABLE PFRMIT rAI I /9nQ1 Q .'i-7r.Q7 t=no Irucnerrinuic CY010ce -1 vim. JOB ADDRESS^' 4i 7 I1C• - CITY/ZIP CROSS STREET APN I 10 S 0 J / -y PARCEL SIZE 10 LAND USE APPLICATION # OWNER 44-1 YK0. -- PHONE hh OWNERADDRESS /�O CITY/STATE/ZIP CONTRACTOR 1L-4-\ 1717 rjS �1h.(I(�j I� , PHONE 7—k-31-7 '51'7-6 / CONTRACTOR ADDRESS �' K 6 E CITY/STATE/ZIP L -4r-4• L kc 4 S-2- �- C-57 WELL DRILLING LICENSE NUMBER Yl6 2- EXPIRATION DATE Z6 LZ ✓a-e.L PERFORATION CONTRACTOR PHONE PERFORATION CONTRACTOR ADDRESS CITY/STATE/ZIP ❑ 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 18'- 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 fp-Open Bottom ❑ Gravel Pack ❑ Uncased ❑ Other Well Log copy attached ❑ Yes ❑ No Grout Seal B• No ❑ Yes _ ____ It below ground surface (bgs) Hole Diameter _ inches Well Conductor Casing ❑ Yes ❑ No Depth of Conductor Casing ft bgs Diameter of Conductor Casing inches Well Casing Diameter_1_0 inches Total Depth _44--_ It Depth to Water_ Sg _ ft Depth of Casing It bgs DESTRUCTION SPECIFICATION, `` Sealing Material from _ 1 w __ft bgs to O 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 fJ Mills Knife _- __i_ -- --- _Number of cuts every -_...,-.____ -._ft and/or _ El Explosives ❑ Detonating cord ❑ with projectiles every _ It ❑ without projectile ❑ Detonating cord and boosters ❑ with projectiles every _ _ ft ❑ without projectile ❑ Other Sealing Material Neat Cement (94 Ib bag/5-6 gal water) Sand Cement 16 •3 sack mix/7 gal water Bentonite Pellets Bentonite (20% solids) Manufacturer Spec % solids_ % Name __. _ . Specs on File Specs Submitted Placement Method X Pumped Free Fall F1 Other Seal Completion pc- Complete with Mushroom Cap ft bgs P 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 LAWS41 . Z Lt I/MU j1Q HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS CONTRACTORS SIGNATURE TITLE �"-" 7 DA Application Accepted By �-- Date Destruction Inspection By Date5�> D7 COMMENTS M� FNr At,G _Eo Area d / ! w I /) Employe/,D# t A PE Codes Sc Info Received B Check#/ Cash Amount Remitted Date Permit/ Service Request # Invoice # Well ID# �,3-)L► 3� ��r z zy EHD08 NI O / I, WELL DESTRUCTION PERMIT 4/30/1212 NOW' ` -I( T