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WELL DESTRUCTION PERMIT <br />PUBLIC WATER SYSTEM I Ye, <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 FXPIRFS 1 YFap Fanu hero lcc+icn <br />JOB ADDRESS 1269 E Grant Line` Road <br />cmrz,o_Tracy, CA 9537716, <br />CROSS STREET } �L ties W APN a`l1 ' Q� t7 ' q I <br />_ <br />ki <br />PARCEL SIZE _LAND USE APPUCATioN N 7 - <br />OWNER Trammell Crow Company <br />PHONE 415-772-0326 <br />OWNER ADDREss 415 Mission Street, 45th Floor <br />_ <br />CITYrsTAT&ZPSan CA 94105 <br />CONTRACTOR L <br />'Francisco, <br />PHONE �01>Q ' O 0 -'?-1 "> � <br />CONT TOR ADDRESS '1 .0-. <br />k <br />TbO <br />CITY/STATE/ZIP 1. J4- C6, Q I / <br />a� <br />WCS7 WELL DRILLING LICENSE NUYBER_� J �S <br />E%PIRATION DATE�'- <br />PERFORATION CONTRACTOR <br />PHONE--- <br />HONE-_PERFORATION <br />PERFORATIONCONTRACTOR ADDRESS <br />CITYISTATEIZP <br />C3 C-57 Well Drilling <br />License Number Expiration Date <br />O Bureau of Alcohol, Tobacco and FxIsanns - Users of Hig . Explosives <br />License Number Expliation fitte _ <br />O CHP Hazardous Matenal Transoonat.on for Explosives <br />License Number Expiration O�FII+ J <br />D San Joaquin County Sheri' -Coroner Explosives Applicatio and Permit <br />L cen¢e Number___ _,_- Expirstid 0ii )Rn C <br />7�j <br />ElCalifomia Occupational Safety Health • Blaster <br />E�'v IV <br />L'cense Number xpiration Date <br />REASON Fog D£slRuCnoN ❑ Dry ❑ Replacement Well ❑ caved In ❑ Pit well Inactive ❑ Test Hoie <br />DetectecJSuspected Well Water Contaminant(&) <br />Adjacent property with contamination (Address) <br />Known SoiL+Wa!or contaminants at adjacent property I <br />i <br />ExlsnNO WELL CONSTRUCTION DETNIA O Open Barlorn Gtw el Pads I ❑ Unca&ed ❑ Oth.' <br />Well Log copy attached ❑ Yes ❑ No Grout Scat ❑ No ❑ Yes <br />ft below ground surface (bps) Hote Diameter inches <br />Well Conductor Casing ❑ Yes O No Depth of Condu Cas��itIng <br />Illi bgs Diameter of Conductor Casing nches <br />Well Casing Diameter L mcnes Total Depth O W' Depth to <br />Water 1TS ' Depth of Casing ft bgs <br />DEBTRUCTION SPECIFICATION <br />Saaiing Material from _ _ D - rt logs to ___.O ft bps Filter Material <br />! from R bgs to __. _ h Dgs <br />Well casing to be perforated by one of the following methods: <br />from ft bgs to ft bgs <br />❑ Mills Knife Number of cuts every and/or <br />-R <br />O Explosives ❑ Detonating Cord D with projectiles every it ❑ without projecUfe <br />C3 Detonating cord and boosters O with projectiles every�ft O without projectile <br />❑ Other _ _ _ _ { <br />_ <br />3 alis Material Neat Cement (94 Ib bapS8 gal water) Sand Cement <br />Pelle s <br />// <br />sack mbr/I gal water ✓untonite <br />Bentonite (20% &oil a) manufacturer Spec % solids % 096 Name <br />Src d ,� �jr s 11 8 f YSpecs or Fiie Specs Submitted <br />Placement Method um Free Fall <br />Other <br />Seal Completion Complete ushroom Cap ft logs Complete to Existing Surface Pad <br />MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS, CALL (209) 953-7697 FOR INSPECTIONS <br />DEPARTMENT USE ONL _ <br />Application Accepted By �- - �i L Date a r. _ Area g fe C <br />Destruction Inspection ByS�ri7H Zq__ Date —zs =?_ Employee IDft <br />COMMENTS <br />v: <br />AI <br />NT <br />rDOA/ y <br />SENT <br />PE SC Reeehfed <br />0 <br />Codesit) <br />Cheddl Amount Date Permly Invoice f1 Well ID# <br />RemlfNd Services uest M <br />X1373 <br />S� �t 1 " 2IDU <br />EHO 43-08 WELL DESTRUCTION PERMIT <br />tt/�, <br />