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WELL DESTRUCTION PERMIT <br />PUBLIC WATER SYSTEM ❑ Yes ❑ No <br />SAN JOAQuiN CouNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 East Hazelton Avenue - STOCKTON CA 95205 - (209) 468-3420 <br />NON-REFUNDABLE PERMIT C41— (209) 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS <br />CROSS STREE <br />OWNER <br />CnY/ZIP <br />SIZE W' LAND USE APPLICATION # <br />CITY/STATE/ZIP <br />CONTRACTOR ADDRESS R { FJV 1 S ' 11�n %6 IQp� 1 A Cr Y/STATEMF 1 � ` 4/w J t V �r jV� % ��7 <br />XC-57 WELL DRILLING LICENSE NUMBER VZZ EXPIRATION DATE <br />PERFORATION CONTRACTOR PHONE <br />PERFORATION CONTRACTOR ADDRESS 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 />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 X Inactive ❑ Test Hole <br />DetectediSuspected Well Water Contaminant(s) <br />Adjacent property with contamination (Address) <br />Known Soil/Water contaminants at adjacent property <br />EXISTING WELL CONSTRUCTION DETAILS X Open Bottom ❑ Gravel Pack ❑ Uncased ❑ Other <br />Well Log copy attached ❑ Yes X No Grout Seal ❑ No ❑ Yes it below ground surface (bgs) Hole Diameter inches <br />Well Conductor Casing ❑ Yes ❑ No Depth of CondUctor Casing ft bgs Diameter of Conductor Casing inches <br />Well Casing Diameter__ inches Total Depth ft Depth to Water V0 it Depth of Casing ft bgs <br />DESTRUCTION SPECIFICATiON <br />Sealing Material from_ ft logs to Q0 ft logs Filler Material_ <br />Well casing to be Derforabed by one of the following methods: <br />❑ Mills Knife Number of cuts every ft and/or <br />❑ Explosives ❑ Detonating cord ❑ with projectiles every_ <br />❑ Detonating cord and boosters ❑ with projectiles every_ <br />from <br />it bgs to gc�jEF/ / <br />ft bgs to ft <br />ft ❑ without projectile <br />ft ❑ without projectile <br />❑ other <br />Pellm <br />paling Material Neat Ceent (94 /b bag . /5-6 gal water) Sand Cement sack m1xl7 gal water <br />ets Bentonite (20% solids) Manufacturer Spec % solids % Name_ <br />Placement Method X---t-Pumped ' Free Fall <br />Seal Completion . C plete with Mushroom Cap It bgs <br />Specs on File <br />Other <br />Complete to Existing Surface Pad <br />.lqN �6 1 <br />SAENVI QUIN C <br />hj� N A IEEN 1 <br />Specs Sub mitten T7 <br />MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS. CALL (209) 953-7697 FOR INSPECTIONS <br />DEPARTMENT <br />Application Accepted By �� <br />Destruction Inspection By. <br />COMMENTS <br />USE ONLY <br />Date �� - d3 Area <br />Date AA IEmployee ID# <br />'FD <br />PE SC Received <br />Codes Into B <br />Check*/ <br />Cash <br />Amount Date Permit/ Invoice alt Well IDS <br />Remitted i Service <br />t. 37s I� i <br />5�- <br />I<<sJ I (i <br />EHD 43-08 J' `I WELL DESTRUCTION PERMIT <br />11/23/21 <br />ry <br />