Laserfiche WebLink
WELL DESTRUCTION PERMIT <br />PUBLIC WATER SYSTEM ❑Yes <br />SAN JOAQUIN 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 />5317 <br />JOB <br />2208 Shoreline Drive <br />CROSS STREET V <br />X Meri <br />1 OWNER <br />Homes of California <br />860 Stillwater Road #200A <br />r ; I I,' <br />_ —CITY/ZIP Manteca 9_ _ _ <br />3-LAI ^ 3121 - 9 PARCEL SIZER 3 <br />•l 7 D USE APPLICATION # <br />CITYISTATElLIP`^'P�t Sacramento CA 95605 <br />PHONElot <br />I f O CITYISTATEIZW C - <br />CONT TOR ADDRESS 3 '� `� S j,,� 1� S --S) ,--, � J <br />H C-57 WELL DRILLING LICENSE NUMBER ` -S 1 a I EXPIRATION DATE II <br />PHONE <br />PERFORATION CONTRACTOR O <br />CITY/STATE/ZIP <br />PERFORATION CONTRACTOR ADDRESS I oo Hw d` L,r�-• -1 7 <br />License Number Sq a I -t- Expiration pate <br />❑ C-57 Well Drilling 99 X335 <br />EIS Bureau of Alcohol, Tobacco and F,rearrns - Users of High Explosives License Number q C -A I 13 GExpiration Date 3I - ;L 0. <br />0 <br />13r CHP Hazardous Material Transportation for Explosives <br />License Number 600 S �'-% _ _ Expiration Date I a - 3) - �" ( 21, <br />9- San Joaquin County Sheriff -Coroner Explosives Application and Permit License Number <br />I % (, I ? Expiration Date <br />�iD''�" <br />,c/ California Occupational Safety Health -Blaster <br />License Number 3 g O I Expiration Date I- <br />REASON FOR DESTRUCTION E] Dry ❑ Replacement Well [3 Caved In C] Pit Well Inactive ❑ Test Hole <br />Detected/Suspected Well Water Contaminant(s) <br />Adjacent property with contamination (Address) <br />Known SoiUWater contaminants at adjacent property---- — - - <br />EXISTING WELL CONSTRU cTION DETAILS ❑ Open Bottom Gravel Pack ❑ Uncased ❑ Other <br />Well Log copy attached ❑ Yes E3 Grout Seal ❑ No ❑ Yes It below round surface (bgs) Hole Diameter Inches <br />Well Conductor Casing 13Yes ET No Depth of Conductor Casing _ ft bgs Diameter of Conductor Casing__._ inches <br />Well Casing Diamoter _ 1kV inches Total Depth 13 o ti Depth to Water R Depth of Casing ft bgs <br />'STRUCTION SPECIFICATION <br />Sealing Material `rom 13 _ ft bgs to ft ods Filler Material <br />Well casing to be perforated by one of the following methods: - from <br />Ills Knife_ Number of cuts evert __ -ft and/or—. <br />'9 Explosives B�Datonating cord [3 with projectiles every 1 O ft <br />❑ Detonatirg cord and boosters ❑ with projectiles ee'ery___ It <br />❑ Other <br />Sealing Material <br />Pallets <br />_from- - ft bgs to <br />ft bgs to ft AE E►ll <br />❑ without projectile Fro O <br />❑ without projectile 4- y <br />---- - -- ---- <br />Neat Cement (941b bag/5-6 gal water) Sand Cement 16 ` sack rnix,7 gal water <br />Bentonite (20% solids) wfacturer Spec % solids °'o Name <br />Placement Method Pumped Free Fall Other <br />Seal Completion Complete with Mushroom Cip 5 ft bgs <br />Specs on File <br />Complete to Existing Surface Pad <br />-NT <br />Ep <br />"N <br />B.Q U1N C7E'A74itC� <br />NTy <br />MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS, CALL (209) 953-7697 FOR INSPECTIONS <br />DEPARTMENT USE ON1,Y 1 <br />.L Date 1, % vl _ Area 3 C <br />Application Accepted By -- <br />Destruction Inspection By Date Z__T Employee ID# <br />COMMENTS 1, "E /T� ' 1 L Vii'. n 0(7 <br />w1, i'1/jrPLS intrir+f�.'/1:/ 111 Ltil l �C �6i t$. <br />Amount <br />Permit/ <br />Invoice # Well IDN <br />I WELL DESTRUCTION PERMIT <br />EHD 43-08 <br />1123121 2 / U �2—/ <br />