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WELL DESTRUCTION PERMIT PUBLIC WATER SYSTEM ❑ Yes ❑ No SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 East Hazelton Avenue - STOCKTON CA 95205 - (209) 468-3420 NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS / EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS �J CITY/ZIP CROSS STREET /� Q APN / ! �� //Q PARCEL SiZEE 7AIPttCANDD USE � APPLICA�TIIONN�# OWNER / G ♦r`/%/^l�iJ�i/C %�i:/1Sr L�� PHONET/ /y,/(/`5j�ydLJ 4 r� OWNER ADDRESS /,4 7-49 �wAgee CITY/STATE/ZIP /`i' y� �_/4 / S z�- CONTRACTOR 06�/Ii'� 141b l/�< � PHONE 3 G vl? CONTRACTOR ADDRESS �i/�Q e� loz� CITY/STATE/ZIP ❑ C-57 WELL DRILLING LICENSE NUMBER EXPIRATION DATE l PERFORATION CONTRACTOR PHONE PERFORATION CONTRACTOR ADDRESS CITY/STATE/ZIP ❑ C-57 Well Drilling License Number Expiration Date 8 1 r .,o ❑ Bureau of Alcohol, Tobacco and Firearms - Users of High Explosives License Number Expiratiom%* �7 2 ❑ CHP Hazardous Material Transportation for Explosives License Number ExpiratiN �IIdd'' /e� U/ N ❑ San Joaquin County Sheriff -Coroner Explosives Application and Permit License Number Expirationwi) r, Tai ❑ California Occupational Safety Health - Blaster License Number Expiration Date Tm9t REASON FOR DESTRUCTION ❑ Dry ❑ Replacement Well ❑ Caved In ❑ Pit Well ❑ Inactive e4VTest Hole Detected/Suspected Well Water Contaminant(s) 'e4ft%G /RGIJL�!'tZdk% Adjacent property with contamination (Address) S S rdi Known Soil/Water contaminants at adjacent property 'rio_ 3' EXISTING WELL CONSTRUCTION DETAILS ❑ Open Bottom ❑ Gravel Pack ❑ Uncased ❑ Other Well Log copy attached ❑ Yes ❑ No Grout Seal ❑ No ❑ Yes ft below ground surface (bgs) Hole Diameter inches Well Conductor Casing ❑ Yes ❑ No Depth of Conductor Casing ft bgs Diameter of Conductor Casing inches Well Casing Diameter inches Total Depth ft Depth to Water ft Depth of Casing ft bgs DESTRUCTION SPECIFICATION Sealing Material from ft bgs to ft bgs Filler Material from ft bgs to ft bgs Well casing to be perforated by one of the following methods: from ft bgs to ft bgs ❑ Mills Knife Number of cuts every ft and/or ❑ Explosives ❑ Detonating cord ❑ with projectiles every ft ❑ without projectile ❑ Detonating cord and boosters ❑ with projectiles every ft ❑ without projectile ❑ Other Sealing Material i Neat Cement (94 Ib bag/5-6 gal water) i Sand Cement sack mix/7 gal water Bentonite�pe,t�2� Pellets Bentonite (20% solids) 1 Manufacturer Spec % solids % Name i Specs on File 1 1 SpepSubmitted Placement Method Pumped - Free Fall Other Zz -3rAkZ0 Seal Completion Complete with Mushroom Cap ft bgs Complete to Existing Surface Pad "+* � MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS, CALL (209) 953-7697 FOR INSPECTIONS DEPARTMENT USE ONLY/ Application Accepted By Date q J`7 q_ Area ! c - Destruction Inspection By�:s up i L -/Date 112( IS -/Z_6' -ZZ Employee ID# COMMENTS �P��YUC�I�r 4f jes-F h-o/e- g55JC';oJC,G1 I�jJJ1 tiyPDOgd463, tjell �e �??OV(nd Cr Md ted/villf rl fi4dor l�po�y'cL11i� T y m Y C O A PE SC Received Codes Info B Check#I Amount Remitted Dat Permit/ Invoice # I eryice equest # Well ID# I-I3L)q )7q�30H EHD 43-08 WELL DESTRUCTION PERMIT 11/23/21