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WELL DESTRUCTION PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPT NON-REFUNnARLE DFRMIT JOB ADORES E NAw S CROSS STREET S V4ALXf-R LN PUBLIC WATER SYSTEM []Yes ❑ No 1868 East Hazelton Avenue-STOCKTON CA 952D5-6232 - (209) 468-3420 J2091 FoR INspEC ms EXPIRES 1 YEAR FROM DATE ISSUED CrTYrZF STS C kTo 0 9 5 -Li S-- #1 a /01 a J�Q! PARCEL SQIZEtY"�_LAN^D USE APPLICA/TIONp# ' b PHONE I l6'n' q 4� f� �c 1 �i'0A y� I CrTY/STATE/ZIP 9b3EV1Lt-If ! CA CONTRACTOR ADDRESS U GOY.41-`(-3b SS CrrYISTATE/2JP!bHCr0J C.pt "IZOIST1E C-57 WELL DRILLING LICENSENUMBER SDO �O ExPIRATION DATE W"'No PERFORATION CONTRACTOR C,A PHONE Well Conductor Casing ❑ Yes PERFORATION CONTRACTOR ADDRESS CrTY/STATEIZJP ft bgs Diameter of Conductor Casing inches Off'—C-57 Well Drilling License Number _�Q��(Qi'$- Expiration Date ii 3 v 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 / Water contaminants at adjacent property EXISTING WELL CONSTRUCTION DETAILS M Open Bottom ❑ Gravel Pack Uncased ❑ Other Well Log copy attached ❑ Yes W"'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 Diameter (Z inches Total Depth 1'71 -ft Depth to Water_S ( ft Depth of Casing It bgs DESTRUCTION SPECIFICATION Sealing Material from I ft bgs to ft bgs Filler Material from It bgs to ft bgs Well g to beperforated by one of the following methods: from it bgs to ft bgs Mills Knife _Number of cuts every _I It and / or ❑ Explosives ❑ Detonating cord ❑ with projectiles every R ❑ without projectile ❑ Detonating cord and boosters ❑ with projectiles every R ❑ without projectile ❑ Other Sealing Material Neat Cement (94 lb bag / 5-6 gal water) X sand Cement �J sack mix 17 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 ' _ ft 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. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS I CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION LAWS. 4£ . . R ADVANCE NOTICE RFOUIRF171 r,':'R±NSPECTIONS CONTRACTORS DEPARTMENT USE ONJ.Y Application Accepted By Date 9IS Destruction Inspectign By _, ^ Date iU) II COMMENTS ��_Li_I_� L 1' J�+��t"M Li%.tif]l.L�"* L Area dle; ClM 1 I/ 1 -- Em1plo,y aID# b :,0-�lv�tri ('T'. int y✓1�� Date Invoice # Well ID# Codes Info ash mitted Service R uest# Re EHD d 411 6�03 / Z^'�.—.r� WELL DESTRUCTION PERMIT revised 4/14Ita // �[ jX