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WELL DESTRUCTION PERMIT PUBLIC WATER SYSTEM [:]Yes rkNo SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPT 1868 East Hazelton Avenue - STOCKTON CA 95205-6232 - (209) 468-3420 NON-REFUNDARI F PFRMIT rAl I 19f1Q1 Qr,3JRQ7 PnD IAICDC!•`TInA1C CYDIDCC 4 V— CAnR• MA— Inn -111 ,/� �;�� ------ JOB ADDRESS ADDRESS�LQ % ��%�1 %Z!L� CITY/ZIP / �G S . CROSS STREET CU ' l'fpi'1APN L) a0 v� PARCEL SIZE !(- LA D USE APPLICATION # / OWNER i%iAF'faSGI {/ 'J �'r4 / { OWNERADDRESS U CS/�f71l41111 ��1O' C fe CITY/STATE/ZIP CONTRACTOR P`WjMTN/S �S�"� PHONE � CONTRACTOR ADDRESS 2/Zd CITY/STATE/ZIP S -//`w /W57 WELL DRILLING LICENSE NUMBER EXPIRATION DATE 2— )GVI/J,IJ/� PERFORATION CONTRACTOR or / 7 PHONE PERFORATION CONTRACTOR ADDRESS CITY/STATE/ZIP ❑ C-57 Well Drilling }� License Number _ Expiration Date P)A Bureau of Alcohol, Tobacco and Firearms - Users of High Explosives License NumbelCA - °%'3s � .-C, a xpiration Date t ' d� CHP Hazardous Material Transportation for Explosives License Number JkDt fs No Ift!-"$0 xpiration Date San Joaquin County Sheriff -Coroner Explosives Application and Permit License Number 0)-00 Expiration Date d o California Occupational Safety Health - Blaster License Number act. i Expiration Date 3 1 Old 16 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 CONSTRUCTION DETAILS ❑ Open Bottom ❑ Gravel Pack ❑ Uncased ❑ Other Well Log copy attached ❑ Yes ❑ No Grout Seal ❑ No ❑ Yes ft below ground surface (bgs) Hole Diameter inches Well Conductor Casing ❑ Yes ❑ No Depth of Conductor Casing ft bgs Diameter of Conductor Casing inches Well Casing Diameter_ AD inches Total Depth i X7(7 ft Depth to Water ft Depth of Casing ft bgs DESTRUCTION SPECIFICATION Sealing Material from X30 ft bgs to 0 ftDgs" Filler Material ---- -from ft bgs to 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 /b bag /5-6 gal water) Sand Cement o' j sack mix / 7 gal water Bentonite Pellets Bentonite (20% splids) Manufacturer Spec % solids % Name IZC;d= �" Specs on File Specs Submitted Placement Method Pumped Free Fall - Other 'idl 44E Seal Seal Completion Complete with Mushroom Cap ft bgs ZZ 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. 7M/17/21014i8� E NOTICE REQUIRED FOR INSPECTIONS CONTRACTORS SIGNATURE!� TITLE �j? J DEPARTMENT USE ONLY Application Accepted By �—/— v Date f' I .� Area 7 // c l Destruction Inspection By. � 1 s Date Employee ID# COMMENTS Well 11Cli,4(.l iP PA 110 F'er ow-Iftr c -t01: See,] �o be oym, plelfcl tc, eAishl sof (7Gf nt'(I - PE Codes SC Info Receivedhec B s Amount Date Permit/ Remitted Service Request # Invoice # Well ID# EHD 43-08 WELL DESTRUCTION PERMIT revised 4/14/18