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It WELL DESTRUCTION PERMIT PU13LJC WATER SYSTEM ❑ Yes ❑ No SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 East Hazelton Avenue-STOCKTON CA 95205 - (209) 46830 NON-REFUNDABLE PERMIT CALL (2n -P) 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUEI JOB ADDRESS J73 / ../ • .5 f • j _CnY/ZIPD/A 1,4o C CROSS STREET _ APN D 5-9 —1 O' - • PARCEL SIZES' SLAND USE APPLICATIION/# OWNER / S'0 C & � •L�Q PHONE (,/P f) / 7 7- 7/LI7 OWNERADDRESS 146-70 Crry/STAATEMp PLe,+-S)fA.N TD CONTRACTOR e1w.'ff/F " G�ONS /NG PHONE `ao9% 57;?, -//-3GQ CONTRACTOR ADDRESS �q -a QSF' C:iGS �2wLLLT GA CITY/STATEMP �mo3/eA� C-57 WELL DRILLING LCENSE NUMBER 7 EXPIRTONDATEK /G1/�PERFORATION CONTRACTOR PHONE PERFORATION CONTRACTOR ADDRESS4SS-S AyBy2� 8LVP ST �( CrY1STATE/ZIP A-"1-AA/0Nrf " C-57 Well Drilling License Number -/.2S-741 Expiration Date 'l 3 /42 Bureau of Alcohol, Tobacco and Firearms - Users of High Explosives License Number Expiration Date CHP Hazardous Material Transportation for Explosives License Number A 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 inche Weil Conductor Casing ❑ Yes ❑ No Depth of Conductor Casing ft bgs Diameter of Conductor Casing inches Well Casing Diameter inches Total Depth 1 79 ft Depth to Water ft Depth of Casing ft bgs DESTRUCTION SPECIFICATION -'A, At L L - Sealing Material from O ft bgs to a' % 11 It bgs Filler Material // SA4 < .5411D Sl. , ft bgs to /Zf 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 everyft ❑ without projectile ❑ Detonating cord and boosters ❑ with projectiles everyft ❑ without projectile ❑ Other Sealing Material ❑ Neat Cement (941b bagl5-6 gal wafer) X Sand Cement // .S _sack mix17 gal water 0 Bentonite Pellets 0 Bentonite (20% solids) ❑ Manufacturer Spec % solids % Name ❑ Specs on File ❑ Specs Submitted Placement Method umpe ❑ Free Fall ❑ Other Seal Completion A Complete with Mushroom Cap 5 � ft bgs ❑ Complete to Existing Surface Pad MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS, CALL (209) 953-7697 FOR INSPECTIONS -�-� JJ DEPARTMENT USE 0 j Application Accepted By �— /! L Z._: Date 17 O F 2 I Area LI1<,4,)6 � k t� �/ . Destruc`Jon Inspection By �. �� 5JL v ( I � Date d LEmployee ID# A COMMENTS ,J (2v..7 �rE�.-) Lf PE SC Codes Info Received 14fiacqVAmount B Remitted Dat Permit! Service Re uest # invoice # 't1FN ell ID# EHD 43-08 WELL DESTRUCTION PERMIT 11/23/21