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� r <br /> WELL DESTRUCTION PERMIT <br /> PUBLIC WATER SYSTEM ❑Yes ❑No <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 East Hazelton Avenue-STocKrON CA 95205 - (209)4683420 <br /> NON-REFUNDABLE PERMIT /� CALL(2ng)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS �D�,•,, 'ZJ �[����TWN�A) ST CrY21P ADl e44 <br /> CROSS STREET 4!s� APN If�� PARCEL$IIZ/Ev_LAAND USE APPLICATION#_ <br /> OWNER PHONE Y7 J_ 7979 (T#'sf <br /> OWNERADDRESSS,470 n <br /> Gu/LLItd CITY/STATE/ZIP ,/"Le.+SkA.'rVV M. <br /> CONTRACTOR eow'fa± aSoNS lNG PHONE 0LOW $33, -/"3!r <br /> CONTRACTOR ADDRESS,) 3 QGtL (fLe-S M[ - ' t�9 Cr1Y/STATE/ZIP A,"O XA M. 9 S3?a <br /> 9 C-57 WELL DRILLING LICENSE NUMBER �Z 7/ Q EXPIRATIOONN DATE 7 3/ /P;?-,7-— <br /> PERFORATION CONTRACTOR 01- LaJ EL-L / PHONE l , 7 do ) 5 � 5/ <br /> PERFORATION CONTRACTOR ADDRESS Al SI SS /��,gyAou BLyy 57 i CITY/STATE/ZIP SgGe�AtG•�'T�G�4 ' A? O <br /> Cly C-57 Well Drilling License Number 4.29-71f Expiration Date? 3/ 1'Z/ <br /> Cad Bureau of Alcohol,Tobacco and Firearms-Users of High Explosives License Number 4-MW03,40 4Aration Date N I s <br /> X CHP Hazardous Material Transportation for Explosives License Number 90 Z Expiration Date / 3 <br /> IX San Joaquin County Sheriff-Coroner Explosives Application and Permit License Number /2/6 Expiration Dated Z.Z <br /> 12!� California Occupational Safety Health-Blaster License Number /034 Expiration Date 10 2 <br /> REASON FOR DESTRUCTION ❑ Dry ❑ Replacement Well ❑ Caved In ❑ Pit Well Inactive ❑ Test Hole <br /> Detected/Suspected Well Water Contaminant(s) <br /> Adjacent property With contamination(Address) <br /> Known Soil/Water contaminants at adjacent property <br /> EXISTING WELL CONSTRUCTION DETAILS ❑ Open Bottom ❑ Gravel Pack ❑ Uncased ❑ Other <br /> Well Log copy attached ❑ Yes ❑ No Grout Seal ❑ No ❑ Yes ft below ground surface(bgs) Hole Diameter inches <br /> Well Conductor Casing ❑ Yes ❑ No Depth of Conductor Casing ft bgs Diameter of Conductor Casing inches <br /> Well Casing Diameter inches Total Depth ft Depth to Water ft Depth of Casing ft bgs <br /> DESTRUCTION SPECIFICATION <br /> Sealing Material from , Z ft bgs to ft bgs Filler Material /� s � ���'y from ft bgs to �- ft bgs <br /> Well casing to be perforated by one of the following methods: from ft bgs to ft bgs <br /> g Mills Knife Number of cuts every ft and/or <br /> p9 Explosives A Detonating cord 9 With projectiles every ,RC2 ft ❑ without projectile <br /> ❑ Detonating cord and boosters ❑ with projectiles everyft ❑ Without projectile <br /> ❑ Other <br /> Sealing Material ❑ Neat Cement(94 lb bag/5-6 gal wafer)❑ Sand Cement //.5A4*4.440 %ack mix17 gal water ❑ Bentonite <br /> Pellets <br /> 0 Bentonite(20%solids) ❑ Manufacturer Spec%solids_% Name ❑ Specs on File ❑ Specs Submitted <br /> Placement Method K Pumped 0 Free Fall ❑ Other <br /> Seal Completion Al Complete With Mushroom Cap 5 ft bgs ❑ Complete to Existing Surface Pad <br /> MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS, CALL(209)953-7697 FOR INSPECTIONS <br /> �j > / DEPARTMENT USE ONLY 1 I <br /> Application Accepted By �(( /�" L 'L— Date /I Z C' Z / Area <br /> Destruction Inspection By t�J r�(,h �r� Date_ l ( Employee ID# <br /> COMMENTS <br /> s c <br /> PE Sc Received Chec Amount Dat Permit/ �+ WellID# <br /> Codes Info B as Remitted Service Re uest# 01- <br /> X13 4 J f 3,15-- Z 'QRp �}- <br /> EHD 43-08 WELL DESTRUCTION PERMIT <br /> 11/23/21 <br />