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4.3WELL DESTRUCTION PERMIT r ]ti PUBLIC WATER SYSTEM ❑ Yes ❑ No SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPT 1868 East Hazelton Avenue - STOCKTON CA 95205-6232 - (209) 468-3420 NON-REFUNDABLE PERMIT CALL 209) 953-7£97 FOR Ib:S -TIONS EXPIRES 1 YEAR FROM DATE ISSUED JOBADDRESS 5113 I (GI ALI N Ste- CITY171P �Chl ®� 95 -LIS - CROSS `` CROSS S�TREEET ,'NALICEIZ LN APN 1 b I d PARCEL SIZE LAANDD USE APPL21CA(TIONN # ,S OWNER3GC-C I ri&A S PHONE 116-- RIA. . — Jc 6 ?8, qL � A 1 OwNeRADDrmsISerCJX'�� Ilp b%3&,,L A5e L7 Q j CIT'/STATT�eZJP LSbiQfV%ILA-f 1 � -I5W --eSt.Itl CONTRACTOR t•{4b�rpl�AM DKIL-11 1'V � PHONE (Il - 3$3-311®316 CONTRACTOR ADDRESS r OyDX 4q.70S-� CITYISTArFZP5ACro, `A ISA el C-57 WELL DRILLING LIICEENsr NUMBER gr -)OTO EXPIRATION DATE1113h 1Z I PERFORATION CONTRACTOR C'e s' m PHONE PERFORATION CONTRACTOR ADDRESS CTTYISTATEIZIP E" -C-57 Well Drilling License Number 11%tO'I Expiration Date j$ °j11 29 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 IV Inactive ❑ Test Hole Detected / Suspected Well Water Contaminant(s) Adjacent property with contamination (Address) Known Soil I Water contaminants at adjacent property EXISTING WELL CONSTRUCTION DETAILSOpen Bottom ❑ Gravel Pack Uncased 1:1 Other Well Log copy attached ❑ Yes Ir/ 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 Dlameter--Z!$�— inches Total Depth k1 ft Depth to Water S1 Depth of Casing It bgs DF.sTRumo,," SPFCIFICATION Sealing Material from J/Lft bgs to . It bgs Filler Material from it bgs to ft bgs Well coming to be erforated by one of the fOilowinQ methods: from R bgs to ft bgs IIS Mills Knife 9 Number of cuts every / It and / or ❑ Explosives ❑ Detonating cord ❑ with projectiles every it ❑ without projectile C3Detonating cord and boosters ❑ with projectiles every ft ❑ without projectile ❑ Other Sealing Material Neat Cement (9d Ib bag / 5-6 gal water) A' Sand Cement i O. sack mix / 7 gal water Bentonite Pellets Bentonite (20% solids) Manufacturer Spec % solids_ % Name Specs on File Specs Submitted Placement Method Pumped Free F Other Seal Completion Complete with Mushroom Cap Y 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. 'Z ADVANCE NOTICE REQLI(REr1 FOR INSPECTIONS ;rA+f n,►AIW4[..c_t� q I CONTRACTORS SIGNATURE Nf�� a TITi c rtnrc `� 7 DEPARTMENT USE 1ON Y Application Accepted By I Date <•5 Destruction Inspection By i - Date --....---- 1>_ - 11 - _ 1_ �_r i . I . i . r RE WENT Check#/ ash EIVEa _ SEP I6 2021 SAN JOA Q HEALTIRO H DE j MENTAL ARTMENT Area r>/er C� r Employee ID# PE Codes SC Received Info Check#/ ash Amount ate Permit' Invoice # Well ID# Remitted ServlceRe est# nil 1 EHD 43-09 DESTRUCTION PERMIT revived estate l�V r1. / 3/ ! / 42—FWELL