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Edw <br />WELL DESTRUCTION PERMIT <br />-4 1,r <br />s WEp <br />PUBLIC WATER SYSTEM ❑ Yes ❑ No <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 East Hazelton Avenue-STOCKfON CA 95205 - (209) 468.3420 <br />NON-REFUNDABLE PERMIT CALL 12n41 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS I ZJ D CRY/ZIP �T D% d ' <br />r� Q_ <br />CROSS STREET /'>'1 NEE/ APN s� �!y� PARCEL/S6IIZ/E'e LAND USE APPLICATION # <br />OWNFR K Q �SD y.,� PHONE yT�O) / 7 /, 7979 lrosf <br />OWNER ADDRESS 14-70 W1,L z rw /C /ZI <br />CITY/STAATEP %LCCA-S/fNNTD, M. <br />CONTRACTOR eg-A,)AIE } SOw/S lAle- PHONE `�09) 53� f/ -3� <br />CONTRACTOR ADDRESS %!9!5E <br />3 �7 <br />CvGS / '" [C1 - p CrTY/STATE0P W,0XA , 19.5-B'71* <br />Pf C-57 WELL DRILUNG LICENSE NUMBER TZ ? 0 EXPIRATION DATE 7 30 -2,0;Z,,;'- <br />PERFORATION CONTRACTOR PHONE <br />PERFORATION CONTRACTOR ADDRESS <br />4 C-57 Well Drilling <br />❑ Bureau of Alcohol, Tobacco and Firearms - Users of High Explosives <br />❑ CHP Hazardous Material Transportation for Explosives <br />❑ San Joaquin County Sheriff -Coroner Explosives Application and Permit <br />❑ California Occupational Safety Health - Blaster <br />ICfTY/STATEIZIP <br />License Number` A -6 -7Y <br />License Number <br />License Number <br />License Number <br />License Number <br />Expiration Date <br />Expiration Date <br />Expiration Date <br />Expiration Date <br />ExDiration Date <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 Q, inches Total Depth ft Depth to Water ft Depth of Casing ft bgs <br />ESIRUCTION JPECIFICATION <br />Sealing Material from ft bgs to q S ft bgs Filler Material <br />Well casing to be perforated by one of the following methods: <br />❑ Mills Knife Number of cuts every ft and/or_ <br />❑ Explosives ❑ Detonating cord ❑ with projectiles every <br />❑ Detonating cord and boosters ❑ with projectiles every <br />Zw J <br />IV <br />/� SrtCK J 4.we from D ftbgs to_ft bgs <br />from It bgs to ft bgs <br />ft ❑ without projectile <br />ft ❑ without projectile <br />❑ Other <br />Sealing Material ❑ Neat Cement (94 Ib bagl5-6 gal water) A Sand Cement 2gl1k sack mix/7 gal water 0 Bentonite <br />Pellets <br />❑ Bentonite (20% solids) 0 Manufacturer Spec % solids % Name 0 Specs on File ❑ Specs Submitted <br />Placement Method X Pumped ❑ Free Fall ❑ Other <br />Seal Completion A Complete with Mushroom Cap $ ft bgs 0 Complete to Existing Surface Pad <br />MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS, CALL (209) 953-7697 FOR INSPECTIONS <br />DEPARTMENT USE ONL <br />Application Accepted By L— � Z Date 12.4 _ Area l S _31� <br />Destruction Inspection By% ��_ _ 7���' Date 2 2 Employee I-p� <br />COMMENTS %a �;�, —0V 1 <br />y <br />d <br />y <br />PE SC Received hec Amount <br />Codes Info B ash Remitted <br />Date <br />Permit/ <br />Service Request # Invoice # II ID# <br />EHD 43-08 WELL DESTRUCTION PERMIT <br />11/23/21 <br />