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WELL DESTRUCTION PERMIT PUBLIC WATER SYSTEM ❑Yes XN. SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPT 1868 East Hazelton Avenue-STOCKTON CA 95205-6232 -(2009)468-3420 NON-REFUNDABLE/PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED Joe ADDRESS 1 ✓6 LE (� A. D CITY/ZIP E`fS_C�1CZ.1D n 9} S 3 4 CROSS STREET ID QY C .APN ZO l 9 O PARCEL SIZEQQ.�AND USE APPLICATION# OROWNE3yO OWNERADDRESS 6.L — O. .CITY/STATE/ZIP E60—Ct.tO CONTRACTORbr-9:5D• PHONE CONTRACTOR ADDRESS I TA Lxul& CITY/STATE/ZIP rn ti9 is C-57 WELL DRILLING LICENSE NUMBQER —{O EXPIRATION DATE PERFORATION CONTRACTOR PERFORATION CONTRACTOR ADDRESS CITYISTATE/ZIP C-57 Well Drilling License Number 2 Expiration Dat I 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 Detected/Suspected Well Water Contaminant(s) Adjacent property with contamination(Address) Known Soil/Water contaminants at adjacent property EXISTING WELL CON TR C I NAILS ❑ Open Bottom ❑ Gravel Pack 13Uncased ❑ Other Well Log copy attached ❑ Yes No Grout Seal ❑ No ❑ Yes It below ground surface(bgs) Hole Diameter inches Well Conductor Casing❑ Yes ❑ No Depth of Conducto Casing It bgs Diameter of Conductor Casing inches Well Casing Diameter__ inches Total Depth ft Depth to Water_ _It Depth of Casing ft bgs DEs IRLCITUN SPECIFI(x1m Sealing Material from OJW19bgs to 1 d V ft bgs Filler Material from ft bgs to ft bgs Well casing to be perforated by one of the foil—owl a methods: from ft bgs to It 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 Sea)ng Material Neat Cement(94 Ib bag/5-6 gal water) Sand Cement sack mix/7 gal water Bentonite Pellets I2(`Bentonite(20%solld!J Manufacturer Spec%solids_% Name Specs on File Specs Submitted Placement Method Pumped Free Fall Other Seal Completion Complete with Mushroom Cap ft bgsComplete 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. MINIMUM_24 HOUR ADVANCE NOTICE REQUIRED FO I SP CTIONS CONTRACTORS SIGNATURE TIT V.�• DATE I �� t Y"' l►,I c)1. 1 Canrtoi- � I %'I(),q l 4 20 B , coU , DEP RTMENT USE O LY HDFp EAljq �' Application Accepted By Date �� Area Destruction Inspection By Date ( \ ?-e_`2� Employee ID# I COMMENTS PE SC Received he Amount Permit/Codes Info B Cash em 'itted pate Service a uest# Invoice# Well ID# i 1 EHD 43-08 WELL DESTRUCTION PERMIT 1015/07