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WELL DESTRUCTION PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPT <br />NON-REFUNDABLE PERMIT <br />JOB ADDRESS�1�� <br />CROSS STREETS§✓ wALkFQ I m <br />OWNER <br />PUBLIC WATER SYSTEM ❑ Yes ❑ No <br />1868 East Hazelton Avenue - STOCKTON CA 95205-6232 - (209) 4583420 <br />INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />'210cKrou _Js 1S - <br />SIZE LLLLANP USE APPLICATION # <br />�2�-~3r311 <br />TTEMP RosEyi t cA 9s w <br />CONTRACTOR ADDRESS _1 o puk Z.g36crCfTYISTATEZPS <br />A <br />_Cot <br />Cot !Intel <br />Q <br />C-57 WELL DRILLING LICENSE NUMBER Sag p� l� <br />ExPIRATION DATEAI 3n� <br />21 <br />PERFORATION CONTRACTOR SAME <br />PHONE <br />PERFORATION CONTRACTOR ADDRESS <br />E"—C-57 Well Drilling <br />CITY/STATE2IP <br />Bureau of Alcohol, Tobacco and Firearms <br />License Number _$ooro� <br />Expiration Date It S 21 <br />-Users of High Explosives <br />CHP Hazardous Material Transportation for Explosives <br />License Number <br />Expiration Date <br />San Joaquin County Sheriff -Coroner Explosives Application and Permit <br />N <br />License umber <br />License Number <br />Expiration Date <br />California Occupational Safety Health - Blaster <br />Expiration Date <br />License Number Expiration Date <br />REASON FOR DESTRUCTION ❑ Dry ❑ Replacement Well ❑ Caved In ❑ Pit Wall <br />Detected / Suspected Well Water Contaminant(s) <br />Inactive <br />❑ Test Hole <br />Adjacent property with contamination (Address) <br />Known Soil / Water contaminants at adjacent property_ <br />EXISTING WELL CONSTRUCTION DETAILS/. Open Bottom ❑ Gravel Pack <br />Well Log copy attached ❑ Yes i No Grout Seal ❑ No ❑ Yes ft below gnd surface Unce (bg 11 Other <br />_ s) Hole Diameter <br />11rouinches <br />Well Conductor Casing ❑ Yes No Depth of Conductor Casing ft bgs Diameter of Conductor Casing inches <br />Well Casing Diameter Inches Total Depth �1_It Depth to Water_ Depth of Casing ft bgsDESTRUCTION SPFCIFI AT'ION <br />Sealing Material from t 7 g it bgs to S ft bgs Filler Material <br />We11 ca g to be erforat d by one of the followin metho s: from ft bgs to bgs <br />fl <br />��� from ft bgs to ft p� <br />aC lt'lIlls Knife �_ Number of cuts every ft and / or <br />❑ Explosives ❑ Detonating cord ❑ with projectiles eve <br />ry ❑ Detonating cord and boosters ❑ with projectiles every ft ❑ without projectile <br />11 Other❑ without projectile <br />Sealing Material Neat Cement (94 Ib bag / 5-6 gat water) Sand Cement 3 <br />Bentonite (20 % solids) Manufacturer Spec % solids % Name — sack mix! 7 gal water Bentonite Pellets <br />Placement Method P —' Specs on File Specs Submitted <br />umped Free Other <br />Seal Completion Complete with Mushroom Cap F ft bgs 9 Complete to Existing Surface Pad <br />I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br />JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br />CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT 1 AM IN COMPLIANCE WITH ALL <br />WORKERS COMPENSATION LAWS. <br />MUM 48 HQUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br />/1 �1 11 1 <br />CONTRACTORS <br />LA <br />I� <br />g <br />R ��MFNr <br />SqN SF 16 <br />e FN✓Oq 20?, <br />- - <br />P4 r), <br />Application Accepted By DEPARTMENT USE ONLY r- <br />Data <br />Destruction Inspec¢on By J <br />COMMENTS Date Employee ID# S <br />I - I n h 15�As � p t. 6µi t.ti s L� f i �' t( <br />revised 4114118 WELL DESTRUCTION PERMIT <br />