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WELL DESTRUCTION PERMIT PUBLIC WATER SYSTEM ❑ Y70No SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE 3" FL - STOCKTON CA 95202 - (209) 468-3420 NON-REFUNDABLE PERMIT CALL (209) 953-7697 FOR INSPECTIONS EXPIRES I YEAR FROM DATE ISSUED JOB ADDRESS zozo'y CITY/ZIP ///�/ - J✓i Date CROSS STREET 4 .Z 'I 1;m APN L�J/ /9O7 � PARCEL SIZE L+AjN/DD USE APPLICATION # 373 A6i OWNER/C rT��C PHONE�� II ►'221 W + �2-111 OWNER ADDRESS L CITY/STATE/ZIP C422!7I CONTRACTOR PHONE CONTRACTOR ADDRESS / CITY/STATE/ZIP ❑ C-57 WELL DRILLING LICENSE NUMBER� EXPIRATION DATE PERFORATION CONTRACTOR PHONE 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 Expiration Date REASON FOR DESTRUCTION ❑ Dry ❑ Replacement Well ❑ Caved In ❑ Pit well 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 ❑ Open Bottom JW Gravel Pack ❑ Uncased ❑ Other Well Log copy attached ❑ Yes ❑ No Grout Seal ❑ No ❑ Yes ft below ground surface (bgs) Hole Diameter inches Well Conductor Casing ❑ Yds ❑ No Depth of Conductor Casing ft bgs Diameter of Conductor Casing inches Well Casing Diameter inches Total Depth f; _ ' _ tt Depth to N% ater 3 'Ne Depth of Casing ft bgs DESTRUCTION SPECIFICATION qa ; Sealing Material from ft bgs to _ ft bgs Filler Material from 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 lb bag /5-6 gal water) ❑ Sand Cement .sack mix / 7 gal water � Bentonite Pellets ❑ Bentonite (20% solids) ❑ Manufacturer Spec % solids % Name ❑ Specs on File ❑ Specs Submitted Placement Method ❑ Pumped Free Fall ❑ Other Seal Completion rV Complete with Mushroom Cap ft bgs ❑ Complete to Existing Surface Pad 1 HEREBY CERTIFY THAT 1 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 1 AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION LAWS. M24 DVANCE NOTICE REQUIRED FOR '.INSPECTIONS CONTRACTORS SIGNATURE TITLE^ DATE %Z •�O DEPARI MEN I U516 V N L Y Application Accepted By Date I %a a l Area Destruction Inspection By Date Employee ID# COMMENTS _ _ A'E'I iP&)-.k ` e 20i .t'"i� J JUA c -r—- �F� Uly Corr - PE SC Codes Info Received Check# BV Amount Remitted Date Permit/ Service Request # Invoice# ' 716- IT 373 A6i *► S II ►'221 W + �2-111 Z EHD 43-02.008 Well Destruction Permit 1/27/2005