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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 3(�� Gh Y�U j�-te. 17 CITY/ZIP C'- LrK-}-t,,•� C( j;�C)C CROSS STREET 1 "ZU'�C 1'1 R [J p•�tt' qPN _ 3-q G 7G Ic I PARCEL SIZE LAND USE APPLICATION OWNER /�C,hiL,� }1 Rc,f # LrK 1 A A PHONE OWNER ADDRESS NWC))CCeojei 7S;G; Ile— ✓QCT CITY/STATEiZIP_: C'S��ES C'C'15� CONTRACTOR_ �l� i C Y `�� ; I` , +� t.� PHONE h70 1A - 2-779 CONTRACTOR ADDRESS P.Cl - `Z 'X CITY/STATE/ZIP �"p, � '�) �{ �"( j I9. C-57 WELL DRILLING LICENSE NUMBER ? •� cl til C EXPIRATIO/N� DATE 7 — � � "" 2 2 /�,. PERFORATION CONTRACTOR ��J yG / °\L ,M r � I C\ �,( e I) • V ��f PHONE f-7Sl PERFORATION CONTRACTOR ADDRESS "I 3C;� o C� 1e 'm CITY/S TATE/ZIP i, L ; .' ,- , -1- I (� ( r_ �\ C t ❑ C-57 Well Drilling 1 I # �,4y r;v�2 r'j 1 zW�� r --\License Number 1 Bureau of Alcohol, Tobacco and Firearms - Users of High Exp�oslves Expiration ation Date License Number ( a" 4r Expiration Date f / liy ❑ CHP Hazardous Material Transportation for Explosives : k 5 License Number Expiration Date �( San Joaquin County Sheriff -Coroner Explosives Application and Permit License Number I `J.t Expiration Date ❑ California Occupational Safety Health - Blaster License Number Expiration Date REASON FOR DESTRUCTION ❑ Dry ❑ Replacement Well ❑ Caved In ❑ Pit Well Inactive ❑ Test Hole Detected/Suspected Well Water Contaminant(s) Adjacent property with contamination (Address) Known Soil/Water contaminants at adjacent property EXISTING WELL CONSTRUCTION DETAILS j4 Open Bottom ❑ Gravel Pack ❑ Uncased ❑ Other NE/R oA Well Log copy attached ❑ Yes No Grout Seal O No Yes ft below ground surface (bgs) Hole Diameter_ i cif Well Conductor Casing ❑ Yes Fel No Depth of Conductor Casing ,, ft bgs Diameter of Conductor Casing inches Well Casing Diameter I C inches Total Depth _ -ft Depth to Water_r '70ftDepth of Casing_ ft bgs DESTRUCTION SPECIFICATION/3.0, 1/�/, Is Sealing Material from ft bgs to _ c' ftbgs Filler Material 1(2.; Se-, K from ft bgs to % ft bgs 9 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 jd Explosives ❑ Detonating cord ❑ with projectiles everyft ❑ without projectile Other JQ s EI cord and boosterwith projectiles every_ t; ft ❑ without projectile ❑ SBaling Material ❑ Neat Cement (94 lb bag/5-6 gal water)X Sand Cement ( sack mix/7 gal water ❑ Bentonite Pelle I I Bentonite (20% solids) ❑ Manufacturer Spec % solids % Name ❑ Specs on File ❑ Specs Submitted Placement Method X Pumped ❑ Free Fall _ ❑ Other 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 Application Accepted �1'L /2 DEPARTMENT USE ONLY / y Date By 3 N Date l�3 / r,� uZ Area t'I / C% Destruction Inspection By r ": L))Date (ler) Employee ID# r; 11 / i S COMMENTS vl�iJd�,�v' flJi^t'r'C'lFC F(If1r1 f'f i �"A'Pih )� PE Codes SC Received Info B Check#/ Amount Cash Remitted Date Permit/ ervice Re uest# Invoice # Well ID# 3 N Ih, EHD 43-08 11/23/21 37039WELL DESTRUCTION PERMIT . �103�- 202 C N r �N 'y T MINT