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WELL DESTRUCTION PERMIT <br /> PUBLIC WATER SYSTEM El Yes XN. <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPT 1868 East Hazelton Avenue-STOCKTON CA 95205-6232-(209)468-3420 <br /> NON-REFUNDABLE PERMIT 11-L(209)953-7697 FOR INSPECTk. EXPIRES 1 YEAR FROM DATE ISSUED <br /> JoBADDRESU-10% C"/Z"kc <br /> CROSS STREET lna� APN 008-100-14:;' PARCEL S1ZE1J'J(0Nt USE APPLICATION# <br /> 0 -ro S <br /> WNER PHONE <br /> OWNER ADDRESS CITY/STATE/ZIP 141 2-7-0 <br /> CONTRACTOR JA e-r\n;U.2�5 6 Ir 05, t)r Q.7tPC_PHONE r-;Li S jib S <br /> CONTRACTOR ADDRESS 101 LaA& ?I.&. _CITY/ST.TErZ.P W 1) , C -9 <br /> C-57 WELL DRILLING LICENSE NUMBER EXPIRATION DATE 5%. <br /> PERFORATION CONTRACTOR PHONE <br /> PERFORATION CONTRACTOR ADDRESS CITY/STATE/ZP <br /> C-57 Well Drilling License Number 29DIB 5 Expiration Date�Ai-22. <br /> Bureau of Alcohol,Tobacco and Firearms-Users of High Explosives License Number Expiration Date <br /> CHP Hazardous Material Transportation for Explosives License Number Expiration Date <br /> San Joaquin County Sheriff-Coroner Explosives Application and Permit License Number Expiration Date <br /> California Occupational Safety Health-Blaster License Number Expiration Date <br /> REASON FOR DESTRUCTION 0 Dry 0 Replacement Well 0 Cavedin El Pit Well X Inactive D Test Hole <br /> Detected/Suspected Well Water Contaminant(s) <br /> Adjacent property with contamination(Address) <br /> Known Soil/Water contaminants at adjacent property <br /> EXISTING WELL CONSTRUCTION DETAILS Open Bottom 0 Gravel Pack 11 Uncased 0 Other <br /> Well Log copy attached 0 Yes 0 No ?'-!r­tSeaI 0 No 0 Yes ft below ground surface(bgs) HoleDiameter inches <br /> Well Conductor C 1 0 Y 0 No Depth of Conductor Casing ft bgs Diameter of Conductor Casing inches <br /> Well Casing iametet" 'e -�es Total Depth It Depth to Watj��� Depth of Casing '2-T5 It bgs <br /> I <br /> DES FRU(TION SPE(IFRATION <br /> Sealing Material from _ () it bgs to 2--1 ft bgs Filler Material from_ft bgs to_ft bgs <br /> Well casing to be perforated by one of the following methods: from ft bgs to_11 bgs <br /> • Mills Knife — Number of cuts every—ft and/or <br /> • Explosives 0 Detonating cord 0 with projectiles every it 0 without projectile <br /> 0 Detonating cord and boosters 0 with projectiles every It 0 without projectile <br /> 0 Other <br /> Sealing Material Neat Cement(94 lb bag/5-6 gal water) Sand Cement 10,5-sack mix/7 gal water Bentonite Pellets <br /> Bentonite(20%solids) Manufacturer Spec;JpQ4d4,_% Name Specs on Fle Specs Submitted <br /> Placement Method Pumped Fal Other <br /> �'Lree�ul <br /> Seal Completion Complete with Mushroom Cap. It bgs Complete to Existing Surface Pac1X <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WrrH 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 24 HOUR ADVANCE NOTICE REQUIRE;,�P.F�ECTIONS <br /> -D <br /> CONTRACTORS SIGNATUREJ�-2?c' 91L*J�13 fit V . P. . 9 <br /> T-- <br /> PAY 61ENT <br /> REC EIVED <br /> HP 0 2021 <br /> SAN JOAQIJIN COUNTY <br /> 4� ENVIRO qMENTAL <br /> HEALTH DI:PARTMENT <br /> XR MENT USE 0 <br /> Application Accepted By Date lo�� Area <br /> 12,yi- Date 1//�J:/iL Employee I <br /> Destruction Inspection By <br /> COMMENTS Z-05-Ir <br /> G <br /> l-"alAied LTs la—, �4, Lli­ 21'Z/.I <br /> P E SC Receive Check#/ Amount Permit/ Invoice# Well ID# <br /> §:odes Info ay I/ ra&h �'� 13.mi".d Service Request# <br /> '-LLWR <br /> Fj <br /> EHD 43-08 WELL DESTRUCTION PERMIT <br /> 10/5107 <br />