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WELL DESTRUCTION PERMIT \� PUBLIC WATER SYSTEM El Yes �I No SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPT 1868 East Hazelton Avenue-STOCKTON CA 95205-6232!-(209)468-3420 NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTK EXPIRES 1 YEAR FROM DATE ISSUED y JOB ADDRESS '` (J �(�V CITYtzIP CROSS STREET % APN 2-LJ5-040- • PARCEL SV' 1 I2*#D USE-APPLICATION# OWNER , PHONE 5ili OWNER ADDRESS k 04 CITY/STATE/ZIP CONTRACTOR \ Q0. PHONE �y ` —IL {�P5 CONTRACTOR ADDRESSvl� CITY/STATE21Pmnc1e—, O-m 9rs ,vUL C-57 WELL DRILLING LICENSE NUMBERR' O � EXPIRATION DATE PERFORATION CONTRACTOR PHONE PERFORATION CONTRACTOR ADD CITY/STATE/ZIP YA C-57 Well Drilling License NumberVIQLJ �3 Expiration Date Il�' 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 Contaml ant(s) Adjacent property with contamination(Address) Known Soil/Water contaminants at adjacent property ExISTING WELL CONSTRUCTION DETAI Cl Open Bottom ❑ Gravel Pack ❑ Uncased ❑ 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 Conductor Casing ft bgs Diameter of Conductor Casing __inches Well Casing Diameter tt inTotal Depth�Q_ft Depth to Water ft Depth of Casing ft bgs c DES FRUCTION SPECIFICATION Sealing Material from U bgs to—_60 ft bgs Filler Material from ft bgs to ft bgs Well casing to be perforated by one of the following methods: from It bgs to ft bgs ❑ Mills Knife Number of cuts every ft and/or ❑ Explosives❑ Detonating cord ❑ with projectiles every It ❑ without projectile ❑ Detonating cord and boosters ❑ with projectiles every ft ❑ without projectile ❑ Other. Sealing Material Neat Cement(94 115 bag/5-6 gal water) Sand Cement sack mix 17 gal water Bentonite Pellets �111entonite(20%soil ds Manufacturer Spec%solids_% Name Specs on File Specs Submitted Placement Method Pumped Free Fall Other Seal Completion Complete with Mushroom Cap It bgs Complete to Existing Surface Pad 1 HEREBY CERTIFY THAT 1 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 REQUICTIONS CONTRACTORS SIGNATURE • TITLE i DATE Ro Uiyco OFp�R�T&/� - MFNT DEPARTMENT USE ONLY C� Application Accepted By L' Date i -d, Area / Destruction Inspection By Date b Employee ID# 066.7 �y COMMENTS PE SC Received Check#1 Amount Date Permit/ Invoice# Well ID# Codes Info By Cash Remitted Service Request# EHD 4308 �/� / � / ��/ WELL DESTRUCTION PERMIT 10!5/07 /�/ -/Y/ �I Lia