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WELL DESTRUCTION PERMIT PUBLIC WATER SYSTEM ❑ Yes ❑ No SAN JOAQUIN COUNTY EWIRONMENTAL HEALTH DEPARTMENT 1868 East Hazelton Avenue - STOCKTON CA 95205 - (209) 468-3420 N nI,J_Qi:rimnaal c Pvaurr ('At t. 17091 953-7697 FAR INSPFCTIONS EXPIRES 1 YFAR FROM ❑ATF ISSUED JOB ADDRESS 2 S O Kee A" Crrr2m S �ecic f ew � �� 95205/ CROSS STREET APN 11-1 - 130 - f90 PARCEL SIZED sf�A1"D USE APPLICATION e OWNER L11I►GwS Weed ,Af PHONE S10- OWNER ADDRESS %150 MtcN 19!Ala AU`G Cm/STATE/LIP 'S+1101"14 fAl CONTRACTOR PHONE 522. 1912$ CONTRACTOR ADDRESS L L9 A Ib#,rS L`' CITY/STATFIMP ' I V Y 1 t4 ISM NT p C-57 WELL DRILLING LICENSE NUMER lda b L (-� EXPIRATION DATE PERFORATION CONTRACTOR PHONE PERFORATION CONTRACTOR ADDRESS CTfY/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 O 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 )5, Inactive ❑ Test Hole Detected/Suspected Well Water Contaminant(s) Adjacent property with contamination (Address) Known Soil/Water contaminants at adjacent property - ---- Fxisn WELL CONSTRUCTION DETAILS 19 Open Bottom ❑ Gravel Pack ❑ Uncased ❑ Other Well Log copy allached ❑ Yes V No Grout Seal ❑ No ❑ Yes It below ground surface (bgs) Hole Diameter __ inches Well Conductor Casing ❑ Yes ❑ No Depth of Conductor Casing it bgs Diameter of Conductor Casing _ inches Well Casing Dlametar-(,._ inches Total Depth 30It Depth to Waterit Depth of Casing - It bgs DESTRUCTION SPECIFICATION Sealing Material from _ft logs to 0 ft bgs Filler Material from It bgs to _ I1 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 ft ❑ without projectile ❑ Detonating cord and boosters ❑ with projectiles every It ❑ without projectile ❑ Other Sealing Material n Neat Cement (94 Ib bag/5-6 gal water) - I Sand Cement _ sack mix17 gal water Bentonite Pellets L Bentonite (20% solids) L Manufacturer Spec % solids-% Name Specs on File Specs Submitted Placement Method -1 Pumped n Free Fail / "I Other Seal Completion i Complete with Mushroom Cap .3 it bgs Complete to Existing Surface Pad I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLIGAIIVN ANO [MAI Inc 1 Vv -1 or= w, .1 . """ 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. lye MAINIMUMXHOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS q CONTRACTORS SIGNATURE rJ`. r--� TITLE CJL.Ao DATE • �� q DEPARTMENT USE ONLY Application Accepted By t� _ DeatRlctlo n tnape�ction By-� COMMENTS ( .'AL1 0 P.: Area Employee IDI 4Z l t EHD 43-08 3 2 Z25074� WELL DESTRUCTION PERMIT ANT FO Z0?1 ° L/Nry c r,�EN r