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PERMIT <br />WELL DESTRUCTION PERMIT <br />Expiration Date <br />PUBLIC WATER SYSTEM El Yes ❑ No <br />SAN JO T L HEALTH <br />AODIR�E� <br />DEPARTMENT 1868 East Hazelton Avenue - STOCKTON CA 95205 - (209) 468-3420 <br />NON-REFUNDABLE PERMIT <br />CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />/1 <br />JOB ADDRESS <br />� j <br />( i ry CITY/ZIP r <br />CROSS STREET yVl K k t'`� <br />APN Z PARCEL SIZE tt&ND USE APPLICATION # <br />OWNER r <br />- S PHONE 6-,oc- <br />OWNER ADDRESS <br />CITY/STATE/ZIP <br />CONTRACTOR `Vt' <br />PHONE j G 2 9f ,P <br />CONTRACTOR ADDRESS /.�� 4Q;. <br />p^f�f <br />x IBJ CITY/STATE/ZIP <br />9<1 C-57 WELL DRILLING LICENSE <br />NUMBER ('- -, (� Z EXPIRATION DATE <br />6-4-' <br />—e <br />PERFORATION CONTRACTOR <br />PHONE <br />PERFORATION CONTRACTOR ADDRESS <br />CITY/STATE/ZIP <br />❑ C-57 Well Drilling <br />License Number <br />Expiration Date <br />❑ Bureau of Alcohol, Tobacco and Firearms - Users of High Explosives <br />License Number <br />Expiration Date <br />❑ CHP Hazardous Material Transportation for Explosives <br />License Number <br />Expiration Date <br />❑ San Joaquin County Sheriff -Coroner Explosives Application and Permit <br />License Number <br />Expirat4an Date <br />❑ California Occupational Safety Health - Blaster <br />License Number <br />ExpiraTi 1% <br />REASON FOR DESTRUCTION ❑ Dry ❑ Replacement Well Caved In ❑ Pit Well ❑ Inactive– <br />�� <br />Detected/Suspected Well Water Contaminant(s) s� <br />Adjacent property with contamination (Address) 2„_ <br />Known Soil/Water contaminants at adjacent property 5,q/y rn <br />UIV <br />EXISTING WELL CONSTRUCTION DETAILS ElOpen Bottom ❑ Gravel Pack ❑ Uncased ElOt4TH DF��M9�tNTA r <br />Well Log copy attached ❑ Yes No Grout Seal V No ❑ Yes It below ground surface (bgs) Hole Diameter ENT inches <br />Well Conductor Casing ❑ Yes No Depth of Conductor Casing — ft bgs Diameter of Conductor Casing inches <br />Well Casing Diameter _ _(a__ inches Total Depth _JCS It Depth to Water _ It Depth of Casing _ 5'�-_ It bgs <br />DESTRUCTION SPECIFICATION <br />Sealing Material frorn ft bgs to It bgs Filler Material _ from ._ ft bgs to ft bgs <br />Well casing to be perforated by one of the following methods: _from It bgs to _ _ ft bgs <br />❑ Mills Knife __Number of cuts every __ ___ft and/or <br />❑ Explosives ❑ Detonating cord ❑ with projectiles every ft ❑ without projectile <br />❑ Detonating cord and boosters ❑ with projectiles every It ❑ without projectile <br />❑ Other <br />Sealing Material Neat Cement (94 Ib bag/5-6 gal water) Sand Cement sack mix17 gal waterj/ Bentonite Pellets <br />9( Bentonite (20% solids) Manufacturer Spec % solids ____% Name _ ___ Specs on File /1 Specs Submitted <br />Placement Method Pumped Free Fall i Other <br />Seal Completion' Complete with Mushroom Cap ft bgs Complete to Existing Surface Pad <br />I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br />JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br />CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br />WORKERS COMPENSATION LAWS. <br />MINIMUM'' Lie <br />ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br />CONTRACTORS SIGNATURE 1111'C C, ), �CL TITLE D " /4;'- DATE <br />�..,�DE ARTMENT USE ON <br />Application Accepted By Date <br />Destruction Inspection By Date <br />COMMENTS <br />PE <br />SC <br />Received <br />ec <br />Amount <br />Date <br />Permit/ <br />vo II ID# <br />odes <br />Info <br />B <br />sh <br />b9emitted <br />Service Request # <br />R7311(21°I.OI <br />1 <br />o <br />EHD 43-08 WELL DESTRUCTION PERMIT <br />4/30/12 <br />FA <br />