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WELL DESTRUCTION PERMIT <br />PUBLIC WATER SYSTEM ❑ Yes ❑ No <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 East Hazelton Avenue - STOCKTON CA 95205 - (209) 468-3420 <br />NON-REFUNDABLE PERMIT CALL 12091953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESSI01 n '� �� h � <br />CITY/ZIP L-L`�t <br />1� <br />CROSS STREET 14(\ I i1 -Y- •�! <br />IZ 1/ APN LJ r f I �' Q / d <br />PARCEL SIZE InC- LAND USE APPLICATION # <br />!� 1 <br />OWNER LZ 1 CSI A `�(1 61i� <br />PHONE p)cq j IA 5-5c 1 <br />r 5L4 <br />I 1 7.2 W <br />OWNER ADDRESS n M e-- <br />CITY/STATE/ZIP <br />CONTRACTOR \J 1 Y 0 C I 11 h <br />PHONE - o �- .27 7 q <br />CONTRACTOR ADDRESS � C, . 6C X 4 <br />CITYISTATE/ZIP L�1 C` A 9 -• � :) <br />n <br />❑ C-57 WELL DRILLING LICENSE NUMBER cx `j �� _ ,7 .� <br />EXPIRATION DATE - 1 ✓' 2� <br />PERFORATION CONTRACTOR <br />PHONE <br />PERFORATION CONTRACTOR ADDRESS <br />CITYISTATE/ZIP <br />❑ C-57 Well Drilling <br />''cc,,,, •' __ <br />License Number ExpiraTrQ <br />❑ Bureau of Alcohol, Tobacco and Firearms -Users of High Explosives <br />_U <br />License Number Expi o�i���T <br />❑ CHP Hazardous Material Transportation for Explosives <br />License Number Expiration'17 FE <br />❑ San Joaquin County Sheriff -Coroner Explosives Application and Permit <br />License Number Expiration Date _ r PO <br />❑ California Occupational Safety Health - Blaster <br />License Number Expiration Date <br />REASON FOR DESTRUCTION Dry ❑ Replacement Well ❑ Caved In ❑ Pit Well ❑ Inactive ❑ Test Hole <br />Detected/Suspected Well Water Contaminant(s) <br />Adjacent property with contamination (Address) <br />Known SoiWdater contaminants at adjacent property <br />EXISTING WELL CONSTRUCTION DETAILS )Q Open Bottom ❑ Gravel Pack ❑ Uncased ❑ Other <br />Well Log copy attached ❑ Yes ,ffi No Grout Seal )q No ❑ Yes <br />It below ground surface (bgs) Hole Diameter inches <br />Well Conductor Casing ❑ Yes 3" No Depth of Conductor Casing <br />ft bgs Diameter of Conductor Casing inches <br />Well Casing Diameters inches Total Depth 7G ff Depth to Water 7C, ft Depth of Casing ft bgs <br />DESTRUCTION SPECIFICATION <br />Sealing Material from 7C% ft bgs to C ftbgs Filler Material <br />_ from It bgs to _ _ft bgs <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 ft and/or <br />❑ Explosives ❑ Detonating cord ❑ with projectiles every <br />ft ❑ without projectile <br />❑ Detonating cord and boosters ❑ with projectiles every <br />ft ❑ without projectile <br />❑ Other <br />Material ❑ Neat Cement (94 lb bag/5-6 gal water)'' Sand Cement sack mix17 gal water 11Bentonite <br />PelletsSealing <br />❑ Bentonite (20% solids) ❑ Manufacturer Spec % solids % Name <br />❑ Specs on File ❑ Specs Submitted <br />Placement Method A Pumped ❑ Free Fall ❑ <br />Other <br />Seal Completion ❑ Complete with Mushroom Cap ft bgs )( Complete to Existing Surface Pad <br />MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS, CALL (209) 953-7697 FOR INSPECTIONS <br />DEPARTMENT USE O LY <br />Application Accepted By ��I — Z- Date � r- Area /f <br />Destruction Inspection By Date Employee ID# <br />COMMENTS SJ;rN t>. i j3 <br />/ c5 x <br />Y <br />V —c2 IVJ� <br />Lr <br />m <br />C <br />PE <br />Codes <br />SC Received Check#1 <br />Info By Cash <br />Amount <br />Remitted <br />Date Permit/ Invoice # Well ID# <br />5erviceRequest # <br />y3 13 <br />jk I <br />r 5L4 <br />I 1 7.2 W <br />EHD 43-08 WELL DESTRUCTION PERMIT <br />11123121 <br />�. N2 /5g3�z <br />