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r Th WELL DESTRUCTION PERMIT ly�� �e,l I �'1 PUBLIC WATER SYSTEM ❑Yes ICY No SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPT 1868 East Hazelton Avenue-STOCKTON CA 95205-6232 -(209)468-3420 NON-REFUNDABLE PERMIT 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED JOBADDRESS W:yM �(OS rn L�1! Cm/LP CROSS STREET W•0 1/��/��7�)Y%Jdo ••AAP�N �`► )�-/IOO' �J PARCEL SIZE Q LANDDJUS APPPLIIC�ATTIION#kyr—�.,— OWNER Qp 1 'I 1 �1 1� •��r y` PHONE 1 O l - 7 7 0-8 L/0 5 n/�o / OWNER A.04SSS Ein , CITY/STATE2IP 'S�['O CcT� 1 i )C�1 9!5X15 CONTRACTOR i111 1 1 HONE :2_(f)CJ—M �,J t -�1&!5 15�+arc CONTRACTOR ADDRESS 7 CITYISTATE21P r�{0 C Ill CA ��7 5511 (� `1/j, c Tn C-57 WELL DRILLING LICENSE NUMBER-2'n O CJ I J EXPIRATION DATE J -3_L- PERFORATION L -PERFORATION CONTRACTOR � PHONE PERFORATION CONTRACTOR ADDRESS CITYISTATE21P Q C-57 Well Drilling License Number 3 Expiration Dale (� 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 nacdve ❑ Test Hole Detected/Suspected Well Water Contaminant(s) Adjacent property with contamination(Address) Known Soil/Water contaminants at adjacent property EXISTING WeLL CONSTRUCTIOND ❑ Open Bottom Gravel Pta—R-ck ❑ Uncased ❑ Other Well Log copy attached ❑ Yes No Grout Seal ❑ No Yes LVPack below ground surface(bgs) Hole Diameter inches Well Conductor Casing❑ Yes No Depth of Conductor Casing �ftbgs Diameter of Conductor CasingInches Well Casing Diameter .inches Total Depth -0N5 It Depth to Water It Depth of CasingINV ft bgs DES TRI;CrIOS SPECIFICATION �p� Sealing Material from �ft bgs to!LS ft bgs Filler Material from ft bgs to R bps Well casing to be perforated by one of the following methfrom it bgs to It bgs ❑ Mills Knife Num ery it and/or ❑ Explosives❑ D cord ❑ with projectiles every ft ❑ Without projectile Detonating cord and boosters ❑ with projectiles every ft ❑ without projectile ❑ Other Seal ng Material Neat Cement(941b bag/5-6 gal water)— Sand Cement sack mix/7 gal water Bentonite Pellets Bentonite(20%solids) ufacturer Spec%solids % Name Specs on File Specs Submitted acement Method um ed Free Fall Other Seal Completion Complete with Mushroom Cap 5 it bgs 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. 1 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. detala�aln,A�_a,unJ 77, vA0.rr^�Ir�lr^vr.n CONTRACTORS SIGNATURE TITL V J" DATE I �—l_�i L- I I �� vpm 2021 Qu/iv ooh ! -I tI i. I i _ j!—i.--#-- — I - — --1 ! ,• D�=PA NLTU SE ONLY Application Accepted By V Date Area Destruction Inspection By - Date Employee ID# COMMENTS -)/ f �V z C PE Sc Received Check* AmountPenniV # Codes 1 fO 8 Remitted P� Service Request# Invoice Well ID# EHD 43-08 WELL DESTRUCTION PERMIT 1015/07