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WELL DESTRUCTION PERMIT e 1-5446,66 PUBLIC WATER SYSTEM ❑ Yes [:]No SAN JOAQUIN COUNTY ENVIRONMENTAL ALTH DEPT �A IV%- 1868 East Hazelton Avenue - STOCKTON CA 95205.6232 - (209) 468-342 NON-REFUNDABLE PERMIT C,kC'," CALL 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED \ � JOB ADDRESS 7. QvIS 874 %/Ii -1 P ILJ O•II CITYIzIP 5/6 7 -Ce. c- R: a CROSS STREET H91 X 13 Q1Cn-F1�\ -+n`CI PN 3 7 PARCEL SIZE 1l•aaLANDDfUSE APPLICATION#o OWNERiG ..CC\M77�A y \D,e It n2 `• \ PHONE ! a- OC &5- q6,? --f / I LA�i OWNER ADDRESS)/(p0 Aism!( Xwk" $u'I'ite #300 CITY/STATFJZIP wea'c )r C.& 9,nR66 f N CONTRACTOR auf5k Cecrff2mn I^C]yf.1 --Tti� CGN• _V PHONE (061- . ry33- fR07T ,Q CONTRACTOR ADDRESS I1 O \!S Kilos CITYISTATEIZIP Q3'S0 8 p C-57 WELL DRILLING LICENSE NUMBER EXPIRATION DATE `� 1, PERFORATION CONTRACTOR PHONE 6 IZ PERFORATION CONTRACTOR ADDRESS CITYISTATEIZIP ❑ 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 y� California Occupational Safety Health - Blaster License Number Expiration Date REASON FOR DESTRUCTION ❑ Dry X Rep laceme,n/t Well ❑ Caved In ❑ Pit Well Inactive E] Test Hole Detected / Suspected Well Water C ntam` inant(s) ' T� Adjacent property with contamination (Address) Known Soil / Water contaminants at adjacent property EXISTING WELL CONSTRUCTION DETAILS ❑ Open Bottom ❑ Gravel Pack ❑ Uncesed lirOtherr0. l L Well Log copy attached 13 Yes 3( No Grout Seal ❑ No V Yes D ft below ground surface (bgs) Hole Diameter of inches Well Conductor Casing %6 Yes ❑ No Depth of Conductor Casing „�5� R bgs Diameter of Conductor Casin Inches Well Casing Diameter 16 inches Total Depth lid ft Depth to Water ^• it Depth of Casing R bgs DESTRUCTION SPF-.CIFICATION Sealing Material from ^5ft bgs to 35-0 ft bgs Filler Material from J25" ft bgs to it bgs Well casing to be perforated by one of the following methods: from R bgs to it bgs ❑ Mills Knife Number of cuts every ft and / or ❑ Explosives ❑ Detonating cord ❑ with projectiles every ft ❑ without projectilePA ❑ Detonating cord and boosters ❑ with pjtojectiles every it ❑ without projectile 4f, X Other V 60 sal { nr Ay �¢ 1� �eL'IC[ ��^ • Y 1 Sealing Material feat Cam ,W of' gal water) Sand Cement sack mix 17 gal water Bentonite Pellets Bentonite (20% solids) MahDFdCturer Spc ° s Name --- Cwi- le Specs Submitted 6/ Placement Method Pumped ° / Other I P- i J: 0A( 2 Seal Completion Complete with Mushroom Cap S ft bgs Comple a ace Pad /� 5 �o�Q 1 HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH p%SAq04QU/NTIFY THAT MY REQUIRED CURRET ANDJOAQUIN N ACTIVETY (WITH THESCAIFORNIA CONTRACTORS STATETATE LAWS, AND RULES AND ULICENSE BOARD AND LATIONS. I ALSO THAT I AM IN COPLIANCE (WITH-' -r /RONC'O'Al � rAt WORKERS COMPENSATION LAWS. H (]EpigR �CNr r MINIMUM 48 OUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - CONTRACTORS SIGNATURE 'Sr—TfTLE f5N^•S�� lt/. �tlli�DATE Ce2AII H e- 1 a, q S, �I w- --� U I -C P uu -"� Y ONL/ DEPARTMENT USE ONLY//Z, r rj �Da ted By P/A1/—M< Date Y r-+ Area El r lM�ction By Date Employee ID# �(1 i K.. ��l y � LL� Q �L"i�i' •-f'idM� r r PE SC Received Check#! Amount Permit/ Date Invoice # Well ID# Codes Info B ash Remitted •ce Re uest# EHD 4308A , o �/� � �� ^ [ �� WELL DESTRUCTION PERMIT