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WELL DESTRUCTION PERMIT PUBLIC WATER SYSTEM ❑ Yes ❑ No SAN JOAQ�IN COUNTY ENVIRONMENTAL HEALTH DEPT 1868 East Hazelton Avenue - STOCKTON CA 95205-6232 - (209) 468-3420 NON -R imnARI F PERMIT rel 1 /9nQ1 QrQ_7RQ7 Eno Iricxrrinuc r=Vo1off0 a vim.., JOB ADDRESS 7sp-seffil-'i e. CITY/ZIP (1E(.`� CROSS STREET Al r R00 Y} W e� APN I -I�%17S �� I PARCEL SIZfLAND USE APPLICATION # OWNERle PHONE � � 1 �� / [ �(� / OWNERADDRESS LA -71-7 Li___j�l�/ -/•� �� / /� CITY/STATE/ZIP/ ��/% r�Aig4Z�� CONTRACTOR YO SSw y -,y s f iL« PHONE ZO42t' :?Z.% CONTRACTOR ADDRESS CITY/STATE/ZIP LO OC ✓ /{ 95'L y I C-57 WELL DRILLING LICENSE NUMBER -v4r8J-Z;5 EXPIRATION DATE L O L z 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 ❑ 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 bas Diameter of Conductor Casing inches Well Casing Diameter inches Total Depth _ t Depth to Water _ft Depth of Casing ft bgs DESTRUCTION SPECIFICATION Sealing Material from O ft bgs to / b 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 J10—Mills Knife / Number of cuts every /D ft and / or r/ /l4 ElExplosives ❑ Detonating cord ❑ with projectiles every ft Elwithout projectile /`t ❑ Detonating cord and boosters ❑ with projectiles every ft ❑ without projectile ❑ Other Sealing Material Neat Cement (94 /b bag/ 5-6 gal water) Sand Cement /O J 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 Complete with Mushroom Cap ft bgs Jog- Complete to Existing Surface Pad I 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 I AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION LAWS. MI UM 48 HOUR ADVANCE NOTICE REQUIRED FOR INSPE70NS J CONTRACTORS SIGNATURE / TITLE &/L�� DATE /O • • Z/ Destruction Inspection By r�,, .S( f� �s,1:t. Hilt _ // Date 1VI ��i� 1 Employee ID# 5 COMM NTS (�lLt LZ s� �4Ia 6 r LUe� h c: -��Y e iAIP t�n(TY�(C, 0 r ��14 17 1 1 i Q e) -k-'n n .G ;.. I D i 1 1 o. (:� '-19 (Y XO C--Ik V' �t� � rn_ c� D .a i' /7k01,0 -1(-C) IC 1 fri PE SC Received Check#/ Amount Date Codes Info Cash Remitted Permit/ Invoice # Well ID# Service Request # EH 43-08 WELL DESTRUCTION PERMIT 65W. revised4/14/18 1 /3ZISZ) J