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r <br /> WELL DESTRUCTION PERMIT <br /> PUBLIC WATER SYSTEM ❑Yes ❑to <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 r <br /> CInZP <br /> JOB ADDRESS <br /> APN PARCEL SIZE411 <br /> LAND USE APPLICATION M <br /> CROSS STRE T <br /> PHONE <br /> OWNER L <br /> CITYISTATE/ZIP <br /> OWNER ADDRESS <br /> PHONE <br /> CONTRACTOR CITY/STATFJZIP <br /> CONTRACTOR ADDRESS <br /> EXPIRATION DATE <br /> ]f� C-57 WELL DRILLING LICENSE NUMBER <br /> PHONE <br /> PERFORATION CONTRACTOR <br /> CITY/STATE/ZIP <br /> PERFORATION CONTRACTOR ADDRESS ration DateP <br /> Expiration License Number <br /> ❑ C-57 Well Drilling Expiration Date <br /> ❑ Bureau of Alcohol,Tobacco and Firearms-Users of High Explosives License Number <br /> License Number Expiration Date <br /> ❑ CHP Hazardous Material Transportation for Explosives <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 Dry ❑ Replacement Well ❑ Caved In ❑ Pit Well ❑ Inactive ❑ Test Hole <br /> Detected/Suspected Well Water Contaminant(s) <br /> Adjacent property with contamination(Address) <br /> Known Soil/Water contaminants at adjacent properly----- <br /> EXISTING <br /> roperty- _ -FXISTING WELL CONSTRUCTION DETAILS ❑ Open Bottom Gravel Pack ❑ Uncased ❑ Other <br /> Well Log copy attached ❑ Yes ❑ No Grout Seal ❑ No ❑ Yes It below ground surface(bgs) Hole Diameter inches <br /> Well Conductor Casing❑ Yes ❑ No Depth of Con» esing It b s Diameter of Conductor Casing_ _-inches <br /> Well Casing Dlsmeter inches Total Depth It Depth to Water it Depth of Casing— _It bgs <br /> DESTRUCTION SPECIFICATION <br /> Sealing Material from �J—ft bgs to it bgs Filler Material----- from_ __.____if bgs to it bgs <br /> Well casing to be perforated by one of the following methods:__ from __it bgs to_ -it bgs <br /> ❑ Mills Knife Number of cuts every fl and/or <br /> ❑ Explosives❑ Detonating cord ❑ with projectiles every it ❑ without projectile <br /> ❑ Detonating cord and boosters ❑ with projectiles every -_It ❑ without prolectite <br /> ❑ Other - --- <br /> Sealing Material n Neat Cement(94 Ib bag/5-6 gal water) Sand Cement sack mix/1 gal water Bentonite Pellets <br /> Bentonite(20%solids) '_! Manufacturer Spec%solids-—% Name-- L Specs on File - Specs Submitted <br /> Placement Method '-I Pumped n Free Fail Other <br /> Seal Completion Complete with Mushroom Cap _ft bgs Complete to Existing Surface Pad <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH 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.. Ia <br /> M UM"ai 1A V l�DANCE NOTICE REQUIRED FOR INS EC•TIIO�(N1+pS I <br /> CONTRACTORS SIGNATURE TITLE `�"" DATE -' <br /> i I <br /> —i— - - <br /> -VII, I <br /> If V1 <br /> ENT <br /> VED <br /> 2021 <br /> Y if �AL <br /> 7 Y <br /> — - �—+ -L -QP R <br /> MENr <br /> —T--t—=7-17— <br /> DEPARTMENT USE ONLY <br /> Application Accepted By A Dale Z 1 Z Area <br /> Destruction Inspection By ff _C1 Date Employee IDM <br /> COMMENTS f4 d C'I�t`J I- TT" "- r� Gv e <br /> PE SC Received CheCkM Amount Date Permit/ Invoice M Well IDM <br /> Codes Into B ash emhted i Service Request M <br /> 373 /to/ / s <br /> WELL DESTRUCTION PERMIT <br /> Jam/✓ VC9 <br />