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WELL DESTRUCTION PERMIT PUBLIC WATER SYSTEM ❑ Yes ❑ No SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 East Hazelton Avenue - STOCKTON CA 95205 - (209) 468-3420 NON-REFUNDARI F PERMIT rel I /9nal otv_7aa7 Cr I...v evin.— ... �.......,___ .__..__ JOB ADDRESS C17YIZIP , C C CROSS STREET APN PARCEL SIZE LAND USE APPLICATION k 1 / DE PARTMENT —-- _.__-- -- L r OWNERY PHONE �� OWNER ADDRESS t Cmv/STATE/ZIPCC . CONTRACTOR I1�1 1 1 PHONE Z Z CONTRACTOR ADORE. Rlpi�fgPillCITY/STATE/ZIP 6 q5-)9_7 C-57 WELL DRILLING LICENSE NUMBER EXPIRATION DATE PERFORATION CONTRACTOR PRONE PERFORATION CONTRACTOR ADDRESS CITY/STATE/ZIP ❑ C-57 Well Drilling License Number Expiration Date ❑ 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 Detacted/Suspected Well W"'r ontaminanl(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 X No Grout Seal ❑ No ❑ Yes --- It below ground surface (bgs) Hole Diameter inches Well Conductor Casing ❑ Yes ❑ No Depthof Conor Casing It�DDb0007sn Diameter of Conductor Casing inches ��Well Casing Dlameter_inches Total Depth It Depth to aterdu W, it Depth of Casing it bgs DESTRUCTION SPECIFICATION Sealing Material from ft bgs to it bgs Filler Material from ...... It bgs to it bgs Well casing to be perforated by one of the following methods: from _ It bgs to_ it 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 _ It ❑ without projectile ❑ Other Sealing Material r Neat Cement (94 Ib bag/5-6 gal wafer) i Sand Cement sack mix17 gal water Bentonite Pellets (2D % solids) -, Manufacturer Spec % solids--% Name _ Specs on File Specs Submitted P�Bentonite ment Method ! Pumped � Free Fall- Completion Complete Mushroom Cap ft bgs Other Complete Seal with _._-_ _3_,_ 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. Ive rM1NIMUNkXHOU.R ADVANCE NOTICE REQUIRED FOR INSPECTIONS CONTRACTORS IFn:�-+ _DATE L l PE I SC I Received I Check#/ I Amount I I Permit/ Codes Info B% Cash Remitted Date Service Request # Invoice # Well ID# EHD 43-08 /✓��J v `' WELL DESTRUCTION PERMIT Application Accepted By Destruction Inspection By - COMMENTS 7/ S/ dv tie i 1T��L�• DE PARTMENT —-- _.__-- -- L r USE ON Date 2'l Date Area Employee IDN PE I SC I Received I Check#/ I Amount I I Permit/ Codes Info B% Cash Remitted Date Service Request # Invoice # Well ID# EHD 43-08 /✓��J v `' WELL DESTRUCTION PERMIT