WP0042508 - Laserfiche WebLink

Home Browse Search

WELL DESTRUCTION PERMIT PUBLIC WATER SYSTEM ❑ Yes 11 SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPT 1868 East Hazelton Avenue - STOCKTON CA 95205-6232 - (209) 468-3420 N(1N_RcFIINne9%1 F PFRYIT in rel I I9nQt Q54.7RQ7 Fno IueoerTlnuc FYPIRFS 1 Vcao Co— n.Tc 1-11— JOB ADDRESS + CfTYZP S L oYv CROSS STREET N e W c cC t F' APN I 'Z1 V O� PARCEL SIZE' LAND USE APPLICATION # (_] OWNER 1 f L PHONE -0,0616- IO Ir J OWNER ADDRESS O CITYIS7ATE/ZIP S O C., (3 I //1� CONTRACTOR TI �� PHONE O -o CONTRACTOR ADDRESS3 O-7 S / - Ni fe/� CITYI$TA7EIZIP_T !-) O if` C-57 WELL DRILLING LICENSE R �3 a- 1 C6 EXPIRATION DATE PERFORATION CONTRACTOR PHONE PERFORATION CONTRACTOR ADDRESS CITYISTATE/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 Explos ves License Number 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 Contaminants) Adjacent property with contamination (Address) Known Scil r Water contaminants at adjacent property EXISTING WELL CONSTRUCTION DETAILS / ❑ Open Bottom Gravei Pack ❑ Uncased ❑ Other Well Log copy attached Cl YesLYNo Grout Seal CINo ElYes it below ground surface (bgs) Hole Diameterinches Well Conductor Casing ❑ Yes 5A. Depth of Conductor CasingE �ft♦bgs Diameter of Conductor Casing inches Well Casing Diameter__bY, inches Total Depth 1410 ft Depth to Water_ 10 _ ft Depth of Casing _ ft bgs DF'.1 TRI'r TION SFF.(-IFF YI'H I\ Sealing Material from 1 ' o it bgs to _ It bgs Filler Material t -�aJ wa-ll from ft bgs to It bp Well casing to be perforated by one of the following methods: from it bgs to It bgs ❑ Mills Knife _Number of cuts everyft and / or _ __ ❑ Explosives ❑ Detonating cord ❑ with projectiles every _ _ _ ft ❑ without projectile ❑ Detonating Core and boosters ❑ with projectiles every _ ft ❑ without projectile ❑ Other Sealin M ement (94 Ib bag / 5-6 gal water) Sand Cement sack mix / 7 gal water Bentonite Pellets BentoniteL(20 % solid Manufacturer Spec °s solids _% Name Specs on File Specs Submitted Placement a Pumped Free Fill Other Seal Completion Complete with Mushroom Cap S ft bgs Complete to Existing Surface Pad I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN 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 UM 48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS 3o�a1CONTRACTORS SIGNATURE �" TITLE I") OnOI^ t -f DATE DEPARTMENT USE O LY 3 �J `I Application Accepted By T— .L_ Dale Z Area V L Destruction Inspection By 'L_�Ci'r Date Employee ID# 046 COMMENTSL. 7 6___l�%W�c: Sj IF. PE Sc Received Check#/ Amount Date Permit/ Invoice N Wall Il)# Codes Info B Cash Remitted Service Re uest # 6 EHD 43-08 A // �' R , / WELL DESTRUCTION PERMIT revised 4r14/18 //�C/IJIJ)Y([-/�"/- r cArls C MINT ct;QED 0220 �ART M � NT