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Ir 17- WELL % WELL DESTRUCTION PERMIT PUBLIC WATER SYSTEM ❑ Yes ❑ No SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 East Hazelton Avenue-STOCKTON CA 95205 - (209) 468.3420 NON-REFUNDABLE PERMIT CALL (2[14) 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS,17-3-7 `J .[�5rOGXT� T• c �OQ� _CITYIZIP AD/ 64 CROSS STREET -yCi�+�J —"✓ s / APN +� >�'/ �� I PARCEL SILZ/E V('1 LAND USE APP(LIjCATION/# OWNER R k / So GO rS �� PHONE (, �D if J / 7 �/ - 7l Tf G TOSA OWNER ADDRESSS 14 70 %l�L Gr�i! R �' CrrY/STATE21P iL e&.50 VTON �j/I• CONTRACTOR (itL,)��%"/'�F' SPAS /NI- PHONE Otow 3 3!r CONTRACTOR ADDRESS `7 U� I Clfe-s Cf qi p CnY/STATEZP �7N�� 9 5 a KC-57 WELL DRIW'NG LICENSE NUMBER 7LZ 7 { o EXPIRATION DATE ! / 3A -2,0 PERFORATION CONTRACTOR DR 46i'1- PHONE (,?//,) / ]� S R �� PERFORATION CONTRACTOR ADDRESS '6-,4vljv-JA1V,0 Sri CRY/STATE21P .7��j�" ' 9 C-57 Well Drilling License Number Expiration' Date w 74 Q" Bureau of Alcohol, Tobacco and Firearms - Users of High Explosives License Number Q-C"733A,6- o aYi on Date `>CHP Hazardous Material Transportation for Explosives License Number YAZEcpirationIDate IP� San Joaquin County Sheriff -Coroner Explosives Application and Permit License Number /�%� / Expiration! Date 2° - California Occupational Safety Health - Blaster License Number 1034 Expiration Date ':oV 2. REASON FOR DESTRUCTION ❑ Dry ❑ Replacement Well ❑ Caved In ❑ Pit Well X Inactive O Test Hole Detected/Suspected Well Water Contaminant(s) Adjacent property with contamination (Address) Known Soil/Water contaminants at adjacent property EXISTING WELL CONSTRUCTION DETAILS Well Log copy attached ❑ Yes ❑ ❑ Open Bottom No Grout Seal ❑ No ❑ Gravel Pack ❑ Uncased ❑ Other ❑ 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 inches Total Depth ;1 5 ft Depth to Water ft Depth of Casing ft bgs DESTRUCTION SPECIFICATION Sealing Material from 41) ft bgs to ;2' .g ft bgs Filler Material// S/¢LK -SAWP from D ft bgs to �- S it 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 AExplosives 4 Detonating cord Z, with projectiles every . G ft ❑ without projectile ❑ Detonating cord and boosters ❑ with projectiles everyft ❑ without projectile ❑ Other Pelleis ling Material ❑ Neat Cement (94 lb bag/5-6 gal water) ❑ Sand Cement /t .5.54z"4—sackmix17 gal water El Bentonite 0 Bentonite (20% solids) 0 Manufacturer Spec % solids _% Name ❑ Specs on File ❑ Specs Submitted Placement Method X Pumped ❑ Free Fall / ❑ Other Seal Completion A Complete with Mushroom Cap S It bgs C Complete to Existing Surface Pad MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS, CALL (209) 953-7697 FOR INSPECTIONS DEPARTMENT USE ONLYJ t, Application Accepted By L Date l Z /0 P?b I Area 1 S tJc k+i 1 �, � y, Destruction Inspection By /7. •J11 S ; i)(" >� Date 12% � }�Z+ 1 Employee ID# b d PE Sc Codes Info Receivedec B Amount Permit/ �/ Well IDA Cash Remitted Dae Service R Muest# LV 1y 2 ' i Y Fti EHD 43-08 WELL DESTRUCTION PERMIT 11/23/21