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WELL DESTRUCTION PERMIT PUBLIC WATER SYSTEM ❑ Yes ❑ No SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPT 1868 East Hazelton Avenue - STOCKTON CA 95205-6232 - (209) 468-3420 N ONl_i IMnARI F OPOMIT i'AI I (im ar;'1-7f Q7 Fr1P INCPFr.TI0NC FXPIRFS 1 YFGR FR(TM nGTF ISSIIFn JOB ADDRESS + .J L j t f' L. 1 '� r ♦ �,f CITY/ZIP 7% % ✓ J , CROSS STREET '1 r b�ti r-�'`_r P�� 1 APN PARCEL SIZE � ND USE APPLICATION # OWNERff'r/7 r. L-�'=€..: r..'fC, �: 'CLC; L '�+n.E.<= _�.c, yf �_s�� PHONE S/ l`'i. _'{ L.r/_�'�,�C� OWNER ADDRESS .{ ' , iP �.L: C- y r % Vr- / CITY/STATE/ZIP r*'r�:7 �/. CONTRACTOR ) �'[L f �`�-f, L'\= '� t t, ✓LC I/ti�L� PHONE CONTRACTOR ADDRESS rtiC��% °i I ��-- ��. ��j `� CITY/STATE/ZIP C-57 WELL DRILLING LICENSE NUMBER�f EXPIRATION DATE PERFORATION CONTRACTOR PHONE PERFORATION CONTRACTOR ADDRESS 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 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 Defected / Suspected!^fell Water Contaminant(s) Adjacent property with contamination (Address) Known Soil / Water contaminants at adjacent property EXISTING WELL CONSTRUCTION DETAILS ❑ Open Bottom ❑ Gravel Pack ❑ Uncased )91 Other _ Well Log copy attached ❑ Yes ❑ No Grout Seal ❑ \o ❑ 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 ft Depth to Water ft Depth of Casing ft bgs Di (-TION SPEC'IFR A7'ION r� `0, 3 S" i•'\ Sealing Material from n ft bgs tor'A/ ft bgs Filler Material rG Ls£r.t'� from ft bgs to 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 every ft ❑ without projectile ❑ Detonating cord and boosters ❑ with projectiles every ft ❑ without projectile ❑ Other Sealing Material Neat Cement (94 lb bag / 5-6 gal water) Sand Cement a OTT1 sack mix /7 gal water Bentonite Pellets Bentonite (20% solids)anufacturer Spec % solids % Name Specs on File Specs Submitted Placement Method a Free Fall Other Seal Completion i ft bgs Complete to Existing Surface Pad rn Y °e y PA eb AfAY ® 8 2018 I HEREBY CERTIFY T I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SA 4JO JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. 1 ALSO CERTIFY THAT MY REQUIRED LICENSE ENV/RQUINCO CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT 1 AM IN COMPLIANCE WITH [ N N O U T WORKERS COMPENSATION LAWS. TN�"PA& 'M N, r MA�I,NN,�_IMU 24 HOU ADVVfA C OTICE REQUIRED FOR INSPECTIONS is CONTRACTORS SIGNATURE V �t-�— `� TITLE y V I '4 .+ e'L DATE DEPARTMENT USE ONLY y Application Accepted By ,i v 1L� Date S -7 ' J Destruction Inspection By Date COMMENTS Area A S I I Trow Employee ID# • l h rM , 10/5/07