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WELL DESTRUCTION PERMIT a PUBLIC WATER SYSTEM ❑ Yes ❑ No SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPT 1868 East Hazelton Avenue - STOCKTON CA 95205-6232 - (209) 468-3420 NON-REFt1NDARl F PERMIT (`AI 1 1911I01 QF.4-79ZQ7 I=nD ILICDCnIn\IQ CYDIoce 4 vim.., c.... JOB ADDRESS G< Z� /—Ir'�.� Sf "✓ze�J CITY/ZIP �Jj C L (a 95 2--v CROSS STREET) O!� I a iN)G ji APN ` O / % PARCEL SIZE I I I LANDUSEAPPLICATION # OWNER / 0 µ ( PHONE Zo1 — JS �% / L/ OWNER ADDRESSl rS� r CITY/STATE/ZIPS /�7c� �%>7� CONTRACTOR j 17 1 'ash v)') PHONE J` CONTRACTOR ADDRESS- L 13 } �1 CITY/STATE/ZIP �S �y GV 04 K3 2iO ^7 C-57 WELL DRILLING LICENSE NUMBER T/ / U 7 6 EXPIRATION DATE / %Al (U 2. 2 � o 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 H alth - Blaster License Number Expiration Date REASON FOR DESTRUCTION Dry ❑ Replacement Well ❑ Caved In ❑ Pit Well ❑ Inactive ❑ Test Hole Detected / Suspected Well Water Contaminant(s) W 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 ❑ Yes 1�yo Grout Seal ❑ No ❑ es _� ft below ground surface (bgs) Hole Diameter inches Well Conductor Casing ❑ Yes No Depth of Conductor Casing _ft bgs Diameter of Conductor Casing tV inches Well Casing Diameter 6, inches Total Depth �ft Depth to Water ft Depth of Casing ft bgs DESTRUCTION SPECIFICATION 1 C Sealing Material from _�ft bgs to ,� ft bgs Filler Material �e-�✓I I'� k IIDS from 90 ft bgs to 3 ft bgs Well casing to be perforated by one of the following methods: from ft bgs to ft bgs ❑ Mills Knife Number of cuts every ft and / or ❑ Explosives ❑ Detonating cord ❑ with projectiles every ft ❑ without projectile ❑ Detonating cord and boosters ❑ with projectiles every ft ❑ without projectile ❑ Other Sealing Material Neat Cement (94 lb bag /5-6 gal water) Sand Cement sack mix / 7 gal water 04Bntonite Pellets Bentonite (20% Solids) Manufacturer Spec olids % Name Specs on File Specs Submitted Placement Method Pumped ;Tree Fall Other Seal Completion Complete with Mushroom Cap 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. 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. MINIMU R A CE NOTICE REQUIRED FOR INSPECTIONS CONTRACTORS SIGNATURE TITLE �`�> > """Y��' DATE -7 2 DEP RTMENT USE ONLY Application Accepted By a Date I 7 Area q/15 Destruction Inspection By Dat d Employee ID# COMMENTS 1111 is Ls,( er" :5e' 1 Je "7 f�� G• PE Codes Sc Info Received Check Amount Date Permit/ Invoice # B ash Remitted Service Request # Well ID# 1.1373 161 6, f1rs- of 21 P I EHD 43-08 WELL DESTRUCTION PERMIT revised 4/14/18 H M a 0 d m