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REASON FOR DESTRUCTION Q Dry Replacement Well Detected I Suspected Well Water Contaminant(s) LVA. Adjacent property with contamination (Address) t---.41 Known Soil / Water contaminants at adjacent property 1.-17.Pi 0 Caved In 0 Pit Well Inactive 0 Test Hole ea License Number ell% t 0 License Number -0 ".Expiration Date License Number IA - z-LIS Expiration Date License Number Expiration Date License Number 01 7. Expiration t Expiration Dat - Expiration Data revised 411418 q I 0 ).• 2. Si" WELL DESTRUCTION PERMIT PUOUC WATER SYSTEM D Yes No SAN JOAOUIN COUNTY ENVIRONMENTAL HEALTH DEPT 1868 East Hazelton Avenue -STOCKTON CA 95205-6232 - (209)468-3420 NON-REFUNDABLE PERMIT CALL (209) 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS 24 0 r MA(...Att-TRAL Oft- _ TrA CROSS STREET Cm lov- Dr. APN ( 01. -4- OWNER ic—Coir-..."-e es. A f (AA LL c OWNER ADDRESS S-44 " omeln Su+ (•-•- CONTRACTOR CA.< e. A. tik C:1) C-dAl CONTRACTOR ADDRESS f '4 4 ir4,•-do-4- 43.11.1 PERFORATION CONTRACTOR ADDRESS r-'/n C-57 Well Drilling Bureau of Alcohol. Tobacco and Firearms - Users of High Explosives CHP Hazardous Material Transportation for Explosives San Joaquin County Sheriff-Coroner Explosives Application and Permit California Occupational Safety Health - Blaster 4 C -57 WELL DRILUNG LICENSNUMBER f PERFORATION CONTRACTOR 4244".. is( tiOr-7PC44 I I-LW CITY/STATE/ZIP IVA EXPIRATION DATE PHONE /.././A z12-4) Fr 6 (-) PA Yiwie r RECEI VED AUG 1 2 2019 SAN oA , evolio lly co H M V TY u sA rH log."2 E rA -ARTiWNT S F1/4 t-C•N. c tit 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. MINIMUM 48 HOUR A NOTICE REQUIRED FOR INSPECTIONS TITLE 13r4 r P.'",r DATE Application Accepted By Destruction Inspection By COMMENTS CONTRACTORS SIGNATURE 12.„T ENT USE Date Date Area Employee 10# 0 L EXISTING WELL CONSTRUCTION DETAILS Well Log copy attached 0 Yes No Well Conductor Casing 0 Yes 0 No Well Casing Diameter inches 0 Open Bottom 0 Gravel Pack 0 Uncased ):Y. Other %-' ^*.-"kof- 4\ Grout Seal 0 No 0 Yes ft below ground surface (bgs) Hole Diameter inches Depth of Conductor Casing ft bgs Diameter of Conductor Casing inches Total Depth t r 0 f t Depth to Water i 0 ft Depth of Casing u.-.1."."4.1t bgs DESTRUCTION SPECIFICATION Sealing Material from 0,4 s ft bgs to ' If bgs Filler Material cs s 44. from fVt4K- ft bgs to Well casing to be perforated by one of the followina methods: from Mills Knife Number of cuts every ft and / or -*IC Explosives 0 Detonating cord 0 with projectiles every 'Detonating cord and boosters 'Fr.. with projectiles every Other Sealing Material Neat Cement (9 4 /b bag / 5-6 gal water) Sand Cement 1 e - 1 sack mix I 7 gal water Bentonite (20% solids _ _Manufacturer Spec % solids % Name Specs on File Placement Method Pumped.> Free Fall Other Seal Completion Comp1eteflEhIushroom Cap ft bgs Complete to Existing Surface Pad Bentonite Pellets Specs Submitted ft bgs ft bgs to • ft bgs ft 0 without projectile 1_5 ft 0 without projectile PE Codes SC Info Received A Checker Amount 'emitted Date a Permit/ Service Re it Invoice p Wl3 1 61 tl5 pupa") f (fCilmliq L4P5' 7 _ 1110.3 3.11S CrrilSTATVZIP S L.) A PHONE N/44 CITY/STATE/ZIP kst-i.(Mv.,NOink. c:I4C0 cirerziP C-A PARCEL SIZE LAND USE APPUCATION # PHONE END 43-08 14 q Lfifq5-te 7 ,4 rAtatfIRED