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WELL DESTRUCTION PERMIT PUBLIC WATER SYSTEM ❑ Yes ❑ No SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPT 1868 East Hazelton Avenue - STOCKTON CA 95205-6232 - (209) 468 NON-REFUNDABLE PERMIT c CALL 209 953-7697 FOR INSPECTIONS �]/,. EXPIRES 1 YEAR FROM FROM DATE ISSUED JOB ADDRESS 658 ( G —J4h a,7,4 Jew �} CITY/ZIP r A,A� %/�, %5 ZZ D CROSS STREET Ttrj�/�� // A � -/ APN Z 5 ©� jy PARCEL SIZE 0b-?- LAND USE APPLICATION # OWNER,� ,/ PHONE 2O % 32,9 !/S 7 OWNER ADDRESS �SjJ% ` �/4iJ4/1�" /�E7 CITY/STATE/ZIPAr/" Of,* 9S" -O CONTRACTOR R g/1PHONE 2/1 772 2'7s% CONTRACTOR ADDRESS AA dOtj e 132-7 CITY/STATE/ZIP�Z x—ILAr / s �L : Z C-57 WELL DRILLING LICENSE NUMBER &?Z /O% '9 EXPIRATION DATE PERFORATION CONTRACTOR PHnNF 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 ExoiratioAM REASON FOR DESTRUCTION X Dry ❑ Replacement Well ❑ Caved In ❑ Pit Well ❑ InactiverE Q D Detected / Suspected Well Water Contaminant(s) Y G Adjacent property with contamination (Address) _ N�j�/ � Known Soil / Water contaminants at adjacent property EXISTING WELL CONSTRUCTION DETAILS X Open Bottom ❑ Gravel Pack P( Uncased ❑ OthER"Fer NMENTAL Well Log copy attached e No Grout Seal ElNo ❑ Yes ft below ground surface (bgs) Hole Diameter 14-g Well Conductor Casing s ❑ No Depth of Conductor Casing ft bgs Diameter of Conductor Casing inches Well Casing Diameter inches Total Depth 97 ft Depth to Water47 1/ ft Depth of Casing ft bgs DESTRUCTION SPECIFICATION �+ Sealing Material from /2- ftbgs to <77 ft bgs Filler Material from /2 -ft bgs to ! ft bgs Well casing to be perforated by one of the following methods: from ft bgs to ft 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 ft ❑ without projectile ❑ Other Sealing Material Neat Cement (94 Ib bag /5-6 gal water) Sand Cement /Q sack mix / 7 gal water Bentonite (20% solids) Manufacturer Spec % solids % Name Specs on File Placement Method Pumped Free Fall Other Seal Completion Complete with Mushroom Cap /2 ft bgs Complete to Existing Surface Pad Bentonite Pellets Specs Submitted 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. ZZ; 4 OUR CE NOTICE REQUIRED FOR.,- INSPECTIONS CONTRACTORS SIGNATURE TITLE _DATE f/— I-- 7OZI Application Accepted By _ Destruction Inspection , By V COMMENTS IIQ� __ . -- I PARTMENT USE ONLY,r Date { I / I Area (lam Date l t 1� Employee ID# �t) C6L(.lV\cI Li9lb%IJ 17'. A)n t dkr v -J M07 PE SC Received Chec Codes Info Bv s Amount Remitted Date Permit] Invoice # Service Re uest # Well ID# 1MI111 3 2.5 mm 2-72 ■■■ ■iii '." ■■mm ■■ ■■■■■■ ■■■■.■ .■■■■■■ ■■■■ ■■■■t"Wo i�r■MI'Ma 1 ■■■ ■■■■■ice".� ■ .■. i■■■■■■■ ■■■■.w:.■ �� ■..■■. ■■.. ■■. ■'� ■ ,, ■■■Fr,:. _ W� .■� . ■■■■■■■■ ■■ AIA-- � ■■.. ■■ .■ ..■ii14. alp''i■ ■C■■..■■i■..■.■■■■■...■ ■■■■. IMM mm ■■I■■�■. ■■■ ... ■■W_■_■�L■ mm ■ ■■■■ ■�■■ ■■.■■. ....■.■...... ...........■.. .� ��... ..■i■■■■■■lmmmm =■"■■■■■■■■ mmm1mmm ■ ■■•■■■■■■■■■■•■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■::■■■■ Application Accepted By _ Destruction Inspection , By V COMMENTS IIQ� __ . -- I PARTMENT USE ONLY,r Date { I / I Area (lam Date l t 1� Employee ID# �t) C6L(.lV\cI Li9lb%IJ 17'. A)n t dkr v -J M07 PE SC Received Chec Codes Info Bv s Amount Remitted Date Permit] Invoice # Service Re uest # Well ID# i b 5 3 2.5 11-C1-1 2-72 EHD 43-08 WELL DESTRUCTION PERMIT revised 4/14/18 -3420