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WELL DESTRUCTION PERMIT PUBLIC WATER SYSTEM ❑ Yes �lo SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 East Hazelton Avenue - STOCKTON CA 95205 - (209) 468-3420 NON-REFUNDARLF PFRMIT CALL (9f191 953-7897 Fr]R INCPFCTI0NS2 FXPIRFR 1 VFAR FRORA f)ATF IccllFn JOB ADDRESS Y71,11 Z /\(/f- CITY/ZIP /% /� •/v' CROSS STREET 47 G S APN 2,,6 -1 l% -� SIZE /3• `)9LAND USE APPLICATION # yy��%/2/CJ OWNER J :5rmg { /'� �j�yC� -,� �i�PiA'RRCE�L PHONE1176 —,q./ 3Z 57ZY ,}* OWNER ADDRESS �� /1N✓% �1�-[�� .7�L /��- -7 vL CITY/STATE/ZIPAA/' /� 4� e4! e L rry CONTRACTORIV-111-e- C -PHONE A// ` CONTRACTOR ADDRESS :2/17� ` —111 -e-C.� - - �J CITY/STATE/ZIP C-57 WELL DRILLING LICENSE NUMBER '� 4816 EXPIRATION DATE /a3 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) Ail) Adjacent property with contamination (Address) Known Soil/Water contaminants at adjacent property _ EXISTING WELL CONSTRUCTION DETAILS Open Bottom ❑ 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 ❑ Yes ❑ No Depth of Conductor Casing ft bgs Diameter of Conductor Casing inches Well Casing Diameter_40 inches Total Depth 7,>�3_ It Depth to Water ft Depth of Casing ft bgs DESTRUCTION SPECIFICATION Sealing Material from © __ft bgs to 3 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 Ib bag/5-6 gal water) 1 Sand Cement sack mixll gal water I-V Bentonite Pellets Bentonite (20% solids) Manufacturer Spec % solids—_—% Name i Specs on File i Specs Submitted Placement Method Pumped Free Fall Other wnp� Seal Completion Complete with Mushroom Cap ft bgs Complete to Existing Surface Pad 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. YO MU ADVANCE NOTICE REQUIRED FOR INSPECTIONS CONTRACTORS SIGNATURE ( iJy -1 TITLE /�`�I�12�-� DATE z Z . .. . ..... . ...... . ...... . ... .. ......... ...... . . . . . ........... --7�-212 � Z= SAN JOAQUIN COUNTY�- ENVIRONMENTAL HEALTH DEPARTMENT, i DEPARTMENT USE ONLY H�/Or lfF Application Accepted By L Date 347/11 Area �5�/ CJr: Destruction Inspection By Date WZ Employee ID# S COMMENTS A)p Well leMew�s C- hg,•se . 4,,,.s e. td be C.t em- ll P�Keey LX1:�}Irz; SVtri:t& perl',>' Mus e_ 1'n 4 n l/LL-)M. a/t 6 (' R U,"7112 h Z) P'A ll rl; 5 L4 - -G_ L.9 k, ) . u)n"'rl f3nrA. W - 5'-,) �v 1) PO D . c,LA i[) 1')'d C' n U-) PE Codes S Info Received Check#/ Cash Amount RemittedService Re uest # Invoice # Well ID# y373 16 i k Ko S 2, rls wPermit/ E H D 43-08 WELL DESTRUCTION PERMIT 4/30/12