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WELL DESTRUCTION PERMIT <br />PUBLIC WATER SYSTEM ❑ Yes ❑ No <br />SAN JOAOuin COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 East Hazelton Avenue - STOCKTON CA 95205 - (209) 468-3420 <br />NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS <br />Cm21P� IM <br />G HT Gi <br />CROSS STREET APN <br />PARCEL SIZE . <br />LAND USE APPLICATION # <br />t av& <br />-4 <br />V0--3 7l <br />OWNER <br />PHONE <br />OWNER ADDRESS <br />CrfY/STATE21P <br />N L <br />j/ N <br />O <br />206 <br />22 2(9 <br />CONTRACTOR 1 11 <br />PHONE 1 <br />CONTRACTOR ADDRESS Y <br />Cm/STATEMP <br />GA <br />C-67 WELL DRILLING LICENSE NUMBER I I P ZELLEXPIRATION <br />DATE <br />PERFORATION CONTRACTOR <br />PHONE <br />PERFORATION CONTRACTOR ADDRESS <br />CrrY/STATE/Z1P <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 />Expiration Date <br />❑ California Occupational Safety Health - Blaster <br />License Number <br />Expiration Date <br />REASON FOR DESTRUCTION ❑ Dry ❑ Replacement Well ❑ Caved In ❑ Pit Well <br />Inactive ❑ Test Hole <br />Detected/Suspected Well Water Contaminant(s) <br />Adjacent property with contamination (Address) <br />Known SoiVWater contaminants at adjacent property <br />EXISTING WELL CONSTRUCTION DETAILS Open Bottom ❑ Gravel Pack ❑ <br />Uncased ❑ Other <br />Well Log ropy attached ❑ Yes 11 No Grout Seal ❑ No ❑ Yes <br />It below ground surface (bgs) Hole Diameter____ inches <br />Well Conductor Casing ❑ Yes ❑ No Depth of Conductor Casing <br />ft Diameter <br />of Conductor Casing inches <br />Well Casing Diameter_ inches Total Depth -0 ft Depth to Waterft <br />Depth of Casing It bgs <br />DESTRUCTION SPECIFICATION <br />A <br />A <br />Sealing Material frau _� ft bgs to _M_ft bgs Filler Material <br />from ft bgs to �S <br />Well casing to be perforated by one of the following methods: <br />❑ Mills Knife Number of cuts every ft and/or <br />from <br />ft bgs to �/ V^ <br />11Explosives ❑ Detonating cord ❑ with projectiles every <br />ft <br />❑ without projectile JA Ar <br />0 <br />62o22 <br />❑ Detonating cord and boosters ❑ with projectiles every <br />it <br />❑ without projeg$e <br />ElOther <br />O q <br />a11ng Material .- Neat Cement (94 lb bag/5-6 gal water)1 Sand Cement <br />sack <br />mix!7 gal water NFgLTH —0U'v7 <br />Pell <br />Bentonite (20% solids) •_ Manufacturer Spec % solids % Name <br />Specs on File Sp"i� �d <br />Placement Method r_Iumped i i Free Fall <br />Other <br />N1 <br />Seal CompletionComplete with Mushroom Cap �' It bgs Complete to Existing Surface Pad <br />MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS, CALL (209) 953-7697 FOR INSPECTIONS <br />DEPARTMENT USE ONLY / <br />Application Accepted By ! CA �� <br />r— 1 L— Date i /J.- AQ Area 1 <br />Destruction Inspection By % Dates I �� la --N _ Employee ID# <br />COMMENTS <br />PE SC Received <br />Codes Info B <br />Check#! <br />h <br />Amount <br />Remitted <br />D Per mft/ Invoice # Well ID# <br />Service Request # <br />73 )co: i <br />Ste— <br />I ��s' <br />I 2�VJ2tyLW9 <br />EHD 43-08 WELL DESTRUCTION PERMIT <br />11/23121 <br />