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WELL DESTRUCTION PERMIT ��- PUBLIC WATER SYSTEM ❑Yes ❑No SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 East Hazelton Avenue-STOCKTON CA 95205 -(209)4683420 NON-REFUNDABLE PERMfT CALL(204)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED 28 Z S �. �rD�j�z�oN Sr CIn'/ZIP D! - JOB ADDRESS -�-�/-� [�. Q CROSS STREET ��r�-/may ]__V APN o SW�!210 - �b PARCEL/-SIT�Z//E16 "LANE)USE APPLICATION# OWNER /So �rS e-LL PHONE ( �) ! 77_ 7979 l Toss OWNER ADDRESS 24.70 l. CITY/STAATFJMP /"LeJt'S/*N"N (fir. CONTRACTOR (i/j'/IJEm �ONS I,n►G PHONE ` 2LOW $32, -J/-3 4� c CONTRACTOR ADDRESS « 3 QG5� cl! 5 rn- c' p CrrYISTATE(LP /VIO� %d J�? KC-57 WELL DRILLING LICENSE NUMBER 7 Z J T 0 EXPIRATION DATE 7 3/ _A/.'7— PERFORATION CONTRACTOR 012• JV r L L PHONE�r /L 531e 'e"311 PERFORATION CONTRACTOR ADDRESS 46 5S A-U/3u R-�+ 6LUP 'T- ` CfrvISrATEIZIP ✓IJ'L �/9-/lheN D S 9/ C-57 Well Drilling License Number S 7 It 4? Expiration Date? Z ?01 Bureau of Alcohol,Tobacco and Firearms-Users of High Explosives License Numberq-O-AO47 33AOO7'c�Uiration Date o It CHP Hazardous Material Transportation for Explosives License Number 90 2- Expiration Date Z///X0 i San Joaquin County Sheriff-Coroner Explosives Application and Permit License Number XJ-0/ Expiration Date!�4.24�2 Califomia Occupational Safety Health-Blaster License Number /op Expiration Date i0ali 'Z 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 SoiVWater contaminants at adjacent property ! EXISTING WELL CONSTRUCTION DETAILS ❑ Open Bottom ❑ Gravel Pack ❑ Uncased ❑ Other Well Log copy attached ❑ Yes ❑ No Grout Seal 13 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 I Well Casing Diameter inches Total Depth ft Depth to Water ft Depth of Casing ft bgs DESTRUCTION SPECIFICATION Sealing Material from O ft bgs to bgs Filler Material from ft bgs to 9S 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 ilk 0 ft and/or Explosives K Detonating cord g with projectiles every �9 ft ❑ without projectile ❑ Detonating cord and boosters M with projectiles everyft D without projectile ❑ Other Sealing Material ❑ Neat Cement(94 Ib bag/5-6 gal wafer)❑ Sand Cement d S/f•CK Sgy9 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 X Complete with Mushroom Cap -15/ ft bgs ❑ Complete to Existing Surface Pad MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS, CALL(209)953-7697 FOR INSPECTIONS DEPARTMENT USE ONLY Application Accepted By L V� Date )'L �I�! Area OL�"i71 Destruction Inspection l t r/LS . Dates ( G�'� Employee ID# COMMENTS A U PE SC Received hec Amount Permit/ Codes Info B sh Remitted Date, Service Re nest# Inv Nj� N Well 1109 UA :a-t3qt'5 EHD 43-08 WELL DESTRUCTION PERMIT 11123/21