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WELL DESTRUCTION PERMIT <br /> PUBLIC WATER SYSTEM ❑Yes ❑No <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 East Hezelton Avenue-STOCKTON CA 95205-(209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS (EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS CITY/ZIP Y C <br /> CROSS STREET 1 Y Y r APN 1 PARCEL SIIZZE(�!"1.0 USE APPLICATIONN y <br /> I <br /> OWNER PHONE <br /> Q <br /> -{ /R/Q C R VA/J;7 <br /> �OWNERADRESS CrTY/STATE/ZIP <br /> CONTRACTOR PHONE 7LL <br /> CONTRACTORADDRESS N CRY/STATE/ZIP M �t A C <br /> C-57 WELL DRILLING LICENSE NUMBER— EXPIRATION DATE_ <br /> PERFORATION CONTRACTOR PHONE <br /> PERFORATION CONTRACTOR ADDRESS CITY/STATEMP <br /> ❑ C-57 Well Drilling License Number Expiration Date <br /> ❑ Bureau of Alcohol,Tobacco and Firearms-Users of High Explosives License Number Expiration Date <br /> ❑ CHP Hazardous Material Transportation for Explosives License Number Expiration Date <br /> ❑ San Joaquin County Shenff-Coroner Explosives Application and Permit License Number Expiration Date <br /> ❑ California Occupational Safety Health-Blaster License Number Expiration Date <br /> REASON FOR DESTRUCTION Dry ❑ Replacement Well ❑ Caved In ❑ Pit Well ❑ Inactive ❑ Test Hole <br /> Detected/Suspected Well Water onteminant(s) <br /> Adjacent property with contamination(Address) <br /> Known Soil/Water contaminants at adjacent property- <br /> EXISTING WELL CONSTRUCTION DETAILS ❑ Open Bottom ❑ Gravel Pack ❑ Uncased ❑ Other <br /> Well Log copy attached ❑ Yes ❑ No Grout Seal ❑ No ❑ Yes_ 11 below ground surface(bgs) Hole Diameter_ _inches <br /> Well Conductor Casing❑ Yes ❑ No Depth of Cond�\uctor Casing it s Diameter of Conductor Casing_ inches <br /> Well Casing Diameter_inches Total Depth 1SFe9_—ft Depth to Water _It Depth of Casing It bgs. <br /> DESTRUCTION SPECIFICATION <br /> Sealing Material from -__ft bgs to A(kCA ft bgs Filler Material Irom_ _ft bgs to it bgs <br /> Well casing to be perforated by one of the following methods: from_ It bgs to it bgs <br /> ❑ Mills Knife Number of cuts every—it and/or <br /> ❑ Explosives❑ Detonating cord ❑ with projectiles every H ❑ without projectile <br /> ❑ Detonating cord and boosters ❑ with projectiles every it ❑ without projectile <br /> ❑ Other <br /> ea m g Material Neat Cement(94/b bagl5-6 gal water) Sand Cement - __sack mix/7 gal water Bentonite Pellets <br /> Bentonite(20%solids) ; Manufacturer Spec%solids._°/ Name L Specs on File Specs Submitted <br /> Placement Method Pumped - Free Fall Other <br /> Seal Complatton plate with Mushroom Cap it bgs t; Complete to Existing Surface Pad <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I 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. `9 <br /> IM�UM�XHIOU DVANCE NOTICE REQUIRED FOR IN PECfTIIONS <br /> CONTRACTORS SIGNATURE -✓�- -- TITLE 1 f/ N1q f DATE MIALLL <br /> t- 1 <br /> - D <br /> 0. <br /> ?021 <br /> IQ�rU) <br /> -- - - - - --- - - -- - -- F� C0 UNTY <br /> Ne <br /> - <br /> Ep RTMENT USE Application Accepted By Date Area <br /> Destruction Inspection <br /> rrB�, 1 Date <br /> 61. Employee I <br /> COMMENTS ACoV�PE SC Received Check#/ Amount Date Permit/ Invoiced Well ID# <br /> Coe i fo Cash Remitted Service Re a 1 <br /> W. i -- <br /> EHD 43-08 WELL DESTRUCTION PERMIT <br />