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WELL DESTRUCTION PERMIT PUBLIC WATER SYSTEM ❑ Yes ❑ No SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 East Hazelton Avenue-STOCKTON CA 95205 - (209) 468-3420 NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED Joe ADDRESS91M Cm/LP Check#/ 2215-0 - 010PARCEL SIZE �-.3 � LA{NND USE APPLICATION % Info CRoss STREETNOV-APN Remitted Service Request N OWNER beNowPHONE a- OWNERADDRESS VZV 1-7 .� CITY/STATEMOP 3, CONTRACTOR Y' 'INUPHONE 21'111' CONTRAADESS 110 I a5-�-�-� CRY/STATEa.P MO I,G Pl C-57 WELL DRILLING LICENSE NUMBER U R lh -2— EXPIRATION DATE • 13O • ')' -1 PERFORATION CONTRACTOR PHONE PERFORATION CONTRACTOR ADDRESS CRY/STATE/LP ❑ C-57 Well Drilling License Number Expiration Date ❑ Bureau of Alcohol, Tobacco and Firearms - Users of High Explosives License Number Expiration Dale ❑ 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 DatectedlSuspected Well Wet r ontaminent(s) Adjacent property with contamination (Address) Known SolWyater contaminants at adjacent property—_-- ExisTiNa WELL CaNsmucnom DETAILS ❑ Open Bottom Gravel Pack ❑ Uncased ❑ Other Well Log copy attached ❑ Yes No Grout Seel ❑ No ❑ Yes It below ground surface (bgs) Hole Diameter inches Well Conductor Casing ❑ Yes ❑ No Depth of Con u r Casing it Diameter of Conductor Casing inches Well Casing Diametet��Inches Total Depth it Depth to Water. it Depth of Casing it bgs. DESTRUCTION SPECIFICATION Sealing Materiel from _1t bgs to It bgs Filler Materiel from it bgs to it bgs Well casing to be perforated by one of the following methods; from it bgs to It bgs ❑ Mills Knife Number of cuts every tt and/or ❑ Explosives ❑ Detonating cord ❑ with projectiles every it ❑ without projectile ❑ Detonating cord and boosters ❑ with projectiles every h ❑ without projectile ❑ Other Sealing Material n Neat Cement (941b bag/5.6 gal water) I I Send Cement sack mix/7 gal water X Bentonite Pellets C Bentonite (20% solids) U Manufacturer Spec % solids_ % Name G Specs on File U Specs Submitted Placement Method n Pumped nFree F n Other Seal Completion 1.1 Complete with Mushroom Cep it bgs U Complete to Existing Surface Pad I HEREBY CERTIFY THAT I HAVE PREPARED IHIS AVFLIUAIIUN AnU rnAr rn- 11— -11..,,,, JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE I: CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALI WORKERS COMPENSATION LAWS. IMUMXHOU DVANCE NOTICE REQUIRED FOR INSPECTIONS /yy/ 7'1j CONTRACTORS SIGNATURE ' `��- Tnr1E* DATE `✓ •v 1 J/ DEPARTMENT USE ONLY G �L� Area �ivl,� e ' l S C%Ci Application Accepted By Dat _ Destruction Inspection By Date Employee IDN s COMMENTS i1(y �JC ii)JY1 J� tJl �� (��l�F:v" PE SC Recelv Check#/ Amount Dal PermlU Invoice N Well IDN ;odes Info Cash Remitted Service Request N a- iD 43-08 n / ^ WELL DESTRUCTION PERMIT �iVNr Fb 2021 TMEL Ty N7"