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Seal Completion Complete with Mushroom Cap ft bgs Complete to Existing Surface Pad e t=5 ft bgs to ft bgs 1.4,1 irit4 ; +le from from ft bgs ft bgs to 0 Pit Well 0 Caved In 0 Inactive 0 Test Hole EXISTING WELL CONSTRUCTION DETAILS 0 Open Bottom 0 Gravel Pack 0 Uncased 0 Other REASON FOR DESTRUCTION 0 Dry 0 Replacement Well Detected / Suspected Well Water Contaminant(s) Adjacent property with contamination (Address) Known Soil / Water contaminants at adjacent property Well Log copy attached 0 Yes 0 No Grout Seal 0 No 0 Yes ft below ground surface (bgs) Hole Diameter Well Conductor Casing 0 Xis 0 No Depth of Conductor Casing ft bgs Diameter of Conductor Casing Well Casing Diameter kTO inches Total Depth i 0(5 _ft Depth to Water a ft Depth of Casing inches inches ft bgs DESTR UCTION SPECIFICATION Sealing Material from 04 ft bgs to 530 ft bgs Filler Material Well casing to be perforated by one of the following methods: Mills Knife Number of cuts every ft and / or Explosives 0 Detonating cord 0 with projectiles every ft 0 without projectile 0 Detonating cord and boosters 0 with projectiles every ft 0 without projectile Other Sealinft Material Neat Cement (94/b bag / 5-6 gal water) Sand Cement sackmix / 1-gal water Bentonite Pellets V Bentonite (20% solids)/ Manufacturer Spec % solids 2.0 % Name tr C a) Dr Specs on File Specs Submitted Placement Method qf Pumped Free Fall Other WELL DESTRUCTION PERMIT PUBLJC WATER SYSTEM rif Yes 0 No SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPT 1868 East HazeIton Avenue - STOCKTON CA 95205-6232 - (209) 468-3420 NON-REFUNDABLE PERMIT . CALL (i99 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS a.--It2 15, , c." .5 fil D. e% 4r. \‘ r\ V ,re 0Y 4CITY/Zie \ (.......,4 c...„. OWNER eV.' DX Ck. IL, , LL HONE 6 0 .., -. 4( 'IA) - 0 004 1X AtPN 4,6' • 'Z... PARCEL SIZE% W.LAND USE •keLICATION # 16 CROSS STRV OWNER ADDRESS evILCJI:1 t A -(4,1•) ICI 0.1. ortr 1--- CITY/STATE/ZIP rn .12,‘,„A it, C,.., • CONTRACTOR C-0...\ \.K2 ioNta, V."- 0 D ; / V't IS CC:1 ..4 -111.1 -t._. PHONE D--(3_5L: 7 to - (:, Li CONTRACTOR ADDRESS 30e) 5 • Vol. ro-(.0 CITY/STATE/ZIP 1 u r 0 c-k__ C. Ok c Vt 14 3 1-‘ '11 e,<" EXPIRATION DATE 7 -- ) t, - 11 C-57 WELL DRILLING LICENSE NUMBER PHONE PERFORATION CONTRACTOR ADDRESS CITY/STATE/ZIP ft PERFORATION CONTRACTOR 0 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 License Number Expiration Date License Number Expiration Date License Number Expiration Date License Number Expiration Date License Number Expiration Date I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION LAWS. REQUIREDpR INSPECTIONS CONTRACTORS SIGNATURE 271714OUR CE NOTICE TITLE.) ,4-V\C-\ DATE t" /11 6 w vi ell To ID e-st tr-‹ LI _ ! E 1/ k mai a.._ . L5 AQ0N cou TM'' N USE OLY Application Accepted By Destruction Inspection By fir/WS PE Codes SC Info Received B he Amount Remitted Date Permit/ Service Request # Invoice # Well ID# "773 /0 , .1._.2.71; 0 etif .c3.10/20 P PU040(0 lq- Centel; ? 1 0 2020 Date 3 / 0/2.1) Area --. 41 NMENTALV7 Date 31 -2-/1 -i 1 Z ) Employee ID# ,..0 PARA/ENT ff_ yky¢.3 ' ..e.A.Pe-eve A . EHD 43-08 revised 4/14/18 WELL DESTRUCTION PERMIT