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WELL DESTRUCTION PERMIT <br /> / PUBLIC WATER SYSTEM ❑Yes ❑No <br /> SAN JoAouiN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1$63 Eat Hazelton Avenue-STOCKTON CA 95205-(209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> rn <br /> J09 ADDREa6 CIrY/ZIP <br /> CROSS STREET APN PARCEL SIZE <br /> USE APPLICATION fF ooe <br /> p - PNOHE Hla.t�i�M/t •gliVl`6 y <br /> 0. R Appp /� Crr1—T.MP 1 t'A cu col a�'i!A <br /> CONTRACTOR 1N _1N\/' PHONE ZZ <br /> CONTRACTOR ADDRESS CRY/STATEMP. A 7, <br /> X- C-57 WELL DRILLING LICENSE NUMBER �� ExPmATION DATE <br /> PERFORATION CONTRACTOR PHONE <br /> PERFORATION CONTRACTOR ADD RIOS Crry/STATEMP <br /> ❑ C-57 Well Drilling License Number Expiration Date <br /> ❑ Bureau of Alcohol,Tobacdu and Firearms-Uses of High Explosives license Number Expiration Date <br /> ❑ CHP Hazardous Material Transportation for Fxploalves license Number Expiration Dale <br /> ❑ San Joaquin County Sheriff-Coroner ExplOSlves Application and Permit License Number Expiration Date <br /> ❑ California Occupational Safety Health-Blaster License Number Expiration Dale <br /> REASON FOR DESTRUCTION Dry ❑ Replacement Well ❑ Caved In ❑ Pit Well ❑ Inactive ❑ Test Hole <br /> Detected/Suspected Well Water ontaminant(a) <br /> Adjacent property with contamination(Address) <br /> Known SoIUWalm contaminants at adjacent property <br /> E=TM WELL CONSTRUCTION DETAILS ❑ Open Bottom ❑ Gravel Pack ❑ Uncased ❑ Other <br /> Well Log copy attached ❑ Yea ❑ No Grout Seat ❑ No ❑ Yes_it below ground surface(bgs) Hole Diameter inches <br /> Well Conductor Cuing❑ es ❑ No Depth of Co ctor Casing it t�qs Diameter of Conductor Casing Inches <br /> Will Casing Dlametat -inches Total Depth ItDepth to Water�it Depth of Casing It bgs. <br /> DESTRucrioN SPEaFicATION <br /> Sealing Material from _fl bps to ft bgs Filter Material from It bgs to ft bgs <br /> Well casing to be Derforsted by one of the following methods: from ft bgs to it bgs <br /> ❑ Mille Knife Number of cuts every it and/or <br /> ❑ Explosives❑ Detonating cord ❑ with projectiles every ft ❑ without projectile <br /> ❑ Detonating cord and boosters ❑ with projectiles every If ❑ without projectile <br /> ❑ Other <br /> kelingMaterial rn Neat Cement(94*beg15-6ga1 water)n Sand Cement sack mix7 gal water n Bentonits Pellets <br /> Berrtonite(20%`so1 Ids) ❑ Manufacturer Spec%solids_% Name ❑ Specs on File J Specs Submitted <br /> Placement Method Pumped n Free Fall -1 Other <br /> Seel Completion plate with Mushroom Cap it bgs Li Complete to Existing Surface Pad <br /> I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH'SAN <br /> JOAOUIN COUNTY ORDINANCES,STATE LAWS, AND RULES AND REGULATIONS. 1 ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> [MUM HOUFtIDVANCE NOTICE REQUIRED FOR III NgP1n'E'CTInONS <br /> CONTRACTORS SIGNATURE Trn DATE <br /> COLI <br /> ?421 <br /> 0/JV <br /> P 74 <br /> TY <br /> L—L— ---:#.—j I <br /> MFNT <br /> EP RTIYIENT USE <br /> Application Accepted Byefj�� Date Area !� <br /> Destruction Inspection By Date Employee I <br /> COMMENTS <br /> PE SC Received Check#/ Amount Permit/ <br /> tJ Invoice# Well ID# <br /> Codes I Into Caah Remitted 'ReaLost# <br /> EHD 43-06 WELL DESTRUCTION PERMIT <br />