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WELL DESTRUCTION PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMEN <br />JOBAOOREas X 1269 E Grant Line Road <br />CROSS STREET <br />OWMER Trammell crow <br />crrow Compi <br />OWNIER ADDRESS",. ' : 5 Mission St <br />PUBLIC WATER SYSTEM ❑ Yes (a No <br />T 1868 East Hazelton Avenue - STGCKTON CA 95205 . (209) 4683420 <br />L 209 953-7697 FOR INSPECTIONS 09 EXPIRES 1 YEAR FROM DATE ISSUED <br />CI,Yrbp A Tracy, CA 95377 <br />PARCEL SIZE 0-tt LAND USE APPLK:ATIONill^t <br />PNONEX 415-772-0326 <br />....n �..n..�vnI I I a w . __YISONi� <br />CONTRACTOR ADDRE CITY/STATLIMP <br />W'C•57WELL DRILLING LICENSE NUMBER Q_-_ EXPIRATION DA' <br />San Francisco, CA 94 <br />PERFORATION CONTRACTOR --PHONE <br />PHONE <br />PERFORATION CONTRACTOR Aoo sas <br />t <br />O <br />C-57 Well Drilling <br />License Number <br />Expiration Date — <br />❑ <br />Bureau of Alcohol, Tobacco and Firearms • Users of High Explosives <br />License Number <br />Expiration Date <br />O <br />CHP Hazardous Materiel Transportation far Explosives <br />License Number <br />Expiration Dale <br />O <br />San Joaquin County Sheriff -Coroner Explosives Application and Permit <br />License Number <br />Expiration Date <br />O <br />California Occupational Safety Health - Blaster <br />License Number <br />Expiration Date <br />u <br />it <br />REAsQ,j}Fog DesTRucTIDN ❑ Dry 0 Replacement Well O Caved In D PR Well Inactive O Test Qjq <br />Delected/Suspected Well Water Contaminant(s)'tr�Il N� <br />Adjacent property vAth contamination (Address)_ I E� <br />Known SoillWaler contaminants at adjacent property___ <br />EXISTING WALL CONs7RUCTION DETAILS ❑ Open Bottom KGrayel Pace ❑ Uncased ❑ Other ;El <br />Well Loy copy attached ❑ Yes ❑ No Grout Seal ❑ No O Yes ft below ground surface (bps) HoleDlam .t AN.lpq <br />Wall Conductor Casing O Yes O No Depth of Conductor Casing ft bgs Diameter of Conductor Casiyt pSTH O Well Casing Diameter6 inches Total Depth 1 O h Depth to Waterfl Depth of Casing oaf <br />Sealing Material from 12.0 ft bgs to 0 _ft fags Fliler Malerfal-11!!�! <br />Well casfng to be perforated by one of the foUgtring malttods: <br />O Mills Knife Number of cuts everyft and/or <br />❑ Exploalvas ❑ Detonating cord O with projectiles every__ <br />O Detonating cord and boosters O with projectiles every_ .. <br />h <br />It <br />from <br />It bgs to_ _ft bgs <br />ft bgs to R bgs <br />O. without projectile <br />O without projectile <br />O other <br />Spall g Material Neat Cement (94 lb bep/S6 gal water) , Sand Cement sack mixt! gat water <br />°@II@ts % 1 / <br />Bentonite (20X solids) <br />ifrtff acturer Spec 9L sdids riQ 56 Name favi we -t1 Q ✓specs on File <br />Placement Method Pumped Frer rail Other <br />Seal Completion Complete ushroom Cap it bgs Complete to Exlsyng Surface Pad <br />W Bentonite <br />Specs Submitted <br />MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS, CALL (209) 953-7697 FOR INSPECTIONS <br />DEPARTMENT USE ONY <br />Application Accepted By Z Date 11/ .gy p? Area fC+LV <br />Destruction Inspection By �!51 Date '� Employee IDN <br />COMMENTS <br />EHO 43-08 WELL DESTRUCTION PERMIT <br />t tn3r2i <br />