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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 yEXPIRES 1 YEAR FROM DATE ISSUED/ JOB ADDRESS�`QTi QZPhyr' > �rCITY/ZIP CROSS STREET :Tf— pi ✓ S 1' 1',0—I q / y APN a1 -77d 6 L� �O' P 3 PARCEL SIZE/'ai t� LAND USE APPLICATION # OWNER .LYi�ii�G/iJJYI =YiCaii�Uf�t�eN PHONE OWNER ADDRESS CONTRACTOR fTo 'V ��— CONTRACTOR ADDRESS G N C-57 WELL DRILLING LICENSE NUMBER PERFORATION CONTRACTOR TV I t> -- PERFORATION PERFORATION CONTRACTOR .001 41, C-57 Well Drilling ' Bureau of Alcohol, Tobacco and Firearms - Users of High Explosives CHP Hazardous Material Transportation for Explosives San Joaquin County Sheriff -Coroner Explosives Application and Permit California Occupational Safety Health - Blaster CITY/STATE/ZIP 5-a ell -on TS -d04 - .PHONE PHONE % 9 527-9 Z'1^2 _ CITY/STATE/ZIP A9 /�33 EXPIRATION DATE PHONE / CITY/STATE/ZIP A License Number i— Expiration Date License Number �.4,P4'C' 5S-14 Expiration Date�/Ty License Number _ /JA,4 Expiration Date License Number 21-b.Z Expiration Date "I O License Number -7 )J 1 Expiration Date REASON FOR DESTRUCTION ❑ Dry ❑ Replacement Well ❑ Caved In ❑ Pit Well Inactive ❑ Test Hole Detected/Suspected Well Water Contaminant(s) Amount Dat Permit/ Invoice # Well ID# Remitted a ice Re est # Adjacent property with contamination (Address) 1(.s Known Soil/Water contaminants at adjacent property 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 /S,!5 inches Total Depth 34'0 ft Depth to Water 3 (7 ft Depth of Casing r 7 ft bgs DESTRUCTION SPECIFICATION Sealing Material from Q ft bgs to 3.5-0 ft bgs Filler Material Well casing to be perforated by one of the following methods: from ft bgs to Q"t_bgs from ft bgs to Alas C ❑ Mills Knife Number of cuts everyft and/or CE�V 14 Explosives 11 Detonating cord ❑ with projectiles everyft ❑ without projectile ®, Detonating cord and boosters A with projectiles every I ft ❑ without projectile AR 3 1:1 Other 0 ?Q� Pellets ling Material Neat Cement (94 lb bag/5-6 gal water))( Sand Cement �% • sack mix/7 gal water /N Bentonite (20% solids) Manufacturer Spec %solids % Name Specs on File H�A Placement Method Pumped Free Fall Other ARr' 'eiv Seal Completion )( Complete with Mushroom Cap ft bgs i 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 O 0a Area 5710e,k +on Destruction Inspection By /' Date b Employee ID# AS COMMENTS r PE Codes SC Info Received Ch By Cash Amount Dat Permit/ Invoice # Well ID# Remitted a ice Re est # 37y 1(.s EHD 43-08 WELL DESTRUCTION PERMIT 11/23/21