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WELL DESTRUCTION PERMIT PUBLIC WATER SYSTEM ❑ Yes ❑ No SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPT 1668 East Hazellon Avenue-STOCKTON CA 95205-6232 - (209)468-1420 NON-REFUNDABLE PERMIT CALL 209 963-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS mAIM11,5A.strut CITYIzIP ' k. CROSS STREET a •yy1 t t Irk • l/� 1 1� l l . Am 13 ci a I o a 2� PARCEL SIZE`�LLAND USE APPLICATION # OwNER Medistar Stockton Rehab, LLC PHONE 713.266.8990 OWNER ADDRESS 7670 Woodway Drive 160 CITYISTATE2IP Houston, TX 77706.3 ,(Suite CONTRACTOR 6 PHONE 20 l J CONTRACTOR ADDRESS P.O' I CITYISTATEIZIP Oh 'V IC -57 WELL DRILLING LICENSE NUMBER V EXPIRATION DATE A 3 I 11/02A PERFORATION CONTRACTOR PHONE PERFORATION CONTRACTOR ADDRESS CITYJSTATEIZIP ❑ 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 Sa Health - Blaster License Number Expiration Date REASON FOR DESTRUCTION Dry ❑ Replacement Well ❑ Caved In ❑ Pit Well ❑ Inactive ❑ Test Hole Detected / Suspected Well Water Contaminarrl(s) N 6 y\ -t Adjacent property with contamination (Address) N 0 !N Known Soil/ Water contaminants at adjacent property Np Yli EXISTING WELL CONSTRUCTION DETAILS ❑ Open Bottom ❑ Gravel Pack ❑ Uncased ❑ Other Well Log copy attached ❑ Yes No Grout Seal ❑ \a ❑ Yes ft below ground surface (bgs) Hole Diameter � Q inches Well Conductor Casing ❑ Yes ❑ No Depth of Conductor Casing ft bgs Diameter of Conductor Casing itches Well Casing Diameter ��inches Total DepthV r1kr)pV.ak Depth to Water%ftj(�wrn It Depth of Casingy(%94%bvJ ftbgs DFSl io'c l ION SPF.CIF7CAITON �l U Sealing Material from ft logs to f logs Filler Material - - - -- from ft logs to ft logs Well casing to be perforated by one of the following methods: _ NO from ft bgs b 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 _ ft ❑ without projectile ❑ Other___ Sealing Material Neat Cement (94 Ib bag /5-6 gat 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 I Complete Mushroom Cap 3 ft bgF Other i -,f Complete to Existing Surface Pad Seal Completion with 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. I 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. MINI 8 F JR AD AN E NOTICE REQUIRED F..qR INSPIECTIONS CONTRACTORS SIGNATURE TITLE ---)"— DATE 2- Z Approximate location, discovered well-pipL 1LTTI7fTi11 r�� c �oPa�NMEN�P�NC %' DEPARTMENT USE ONLY 1 ) 1 \�kO tion\ Accepted By N Date r� �Q a 1 _ Arm S TO�C/IC Destruction Inspection By �I �,t� Date 2 Employee IDff DA COM ENTS I'r�n V/YSJ/tl� YOYI' ( Srn e GC/1 -j0 e (ctVAflell f S ' 6e r/ Q /.i In XC a crct c 11 e6f,s jrSl�e the t'LiI ch r4 s i t b A g12 i-Iwlsecexlsflnexec, io 1 yvtv,Mr; JV /YI PE SC Received Chee Amount Dat PermiU Invoke R WeII1D# Codes Info By ash Remittedi e Re uest # Li 73 1k, l - 1c1S i✓ r 17 1, EHD 4308 revised 4/14/18 WELL DESTRUCTION PERMIT