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' WELL DESTRUCTION PERMIT PUBLIC WATER SYSTEM ❑ Yeas SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPT 1868 East Hazelton Avenue - STOCKTON CA 95205-6232 - (209) 468.3420 953 7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED NON-REFUNDABLE PERMIT CALL (209) a- cii� VV Q CITY(ZIP JOB ADDRESS ` Q A �- 1 ` 1 PARCEL SIZE "S LAND USE APPLICATION # CROSS STREETW „ (��D LA �1 \� Y"� OWNER_ 11f O� �- PHONE i, b I CITY/STATE/ZIP OWNER ADDRESS W' rl.f �' Ti GO PHONE CONTRACTOR AT -{ r^ Q CONTRACTOR ADDRESS LAl CITYISTATE/ZIP C-57 WELL DRILLING LICENSE NUMBER _ EXPIRATION DATE PERFORATION CONTRACTOR 'EV ISI. PHONE PERFORATION CONTRACTOR ADDRESS F`r 1-p CITY/STATE/ZIP C-57 Well Drilling License Number Expiration Date Bureau of Alcohol. Tobacco and Firearms - Users of High Explosives License Number Expiration Date CHP Hazardous Material Transportation for Explosives License Number Expiration Date San Joaquin County Shenff-Coroner Explosives Application and Permit License Numoer Expiration Date California Occupational Safety Health - Blaster License Number Expiration Date REASON FOR DESTRUCTION ❑ Dry Replacement Well ❑ Caved Ir ❑ Pit Well Cl Inacfve ❑ Test Hole Detected / Suspected Well Water Contaminant(s) Adjacent property with contamination (Address) Known Soil / Water contaminants at adjacent property__._ --- -------_---- -- EXISTING WELL CONSTRUCTION DETAILS - ❑ Olsen Bottom Gravel Pack ❑ y Uncased ❑ Other _ Hole Dlameter fl Inches Well Log copy altacned ❑ YOS Grout Seal ❑ \n [JYes it below ground surface lbgsi Well Conductor Casing ❑ Yes No Depth of Conductor Casing -_ ft b9 s Diameter of Conductor Casing. inches Well Casing Diameter ti inches Total Do _ I •iaft Depth to ate,_ tt Depth of Casing j 30 ft bgs DF. TRI ( Fii IN 51'Ft If 1( N1Tul Material from It bgS to ��_ ft bgs Filler Material- (� 4n1�c�1 I = from ft logs to h bgs Sealing _� Well casing to be perforated by one of the following methods: from ft bgs to fl bgs ❑ Mills Knife Number of cuts every _ ft and I or ❑ Explosives ❑ Detonating cord ❑ with projectiles every ft ❑ without projectile ❑ Detonating cord and boosters ❑ with projectiles every ft ❑ without projectile ❑ Other Seal g�6asorret��e ment (94 lb bag/ 5-6 gal water) Sand Cement sack mix 17 gal water Bentonite Pellets Bentonite (20 % solid Ifacturer Spec % solids a.�oro Name Specs n File Specs Submitted Placement e i\—mped Free Fall Other Seal Completion Complete wi room Cap I ': Dgs Ccwc to to Existing Surface Pad .,ro rulTu cnu I HEREBY CERTIFY THAT I HAVE PREPAREU IHIb At I'Ll.A11 ry — -1- i— -.-1 •-- -- -- -- - ----- JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION LAWS. Mi N' n )UR ADVANCE NOTICE REQUIRED FOR INSPECTIONS DEPARTMENT USE ONLY Application Accepted By II �-� Date Area Destruction Inspection By Date 1 Lit Employee ID# COMMENTS 1^11K 711 r'�% 'L��"rtr��t/ �N%Z��l�� )L� �ilStll`t/ �)/�:r�lJl�•/nnv:P. � a PE Sc Received Check#I Amount Permit/ Invoice # Well ID# Codes Info 8 ash RemlNed ate ervice V=est # �{3t3 h 1 F r 110m ° EHD 43-08 WELL DESTRUCTION PERMIT revised 4114'18