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DEPARTMENT USE OiLY, <br />Date deV(2,7 <br />Date <br />3/1- ei /vp <br />Employee ID# us <br />Area <br />(K, Application Accepted By <br />Destruction Inspection By <br />WELL DESTRUCTION PERMIT <br />PUBLIC WATER SYSTEM I=1 Yes til,No <br />1868 East Hazeiton Avenue - STocKTON CA 95205 - (209)468-3420 <br />CALL (209) 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> CnVZIP Likktn VI CI& • 611.7o. <br />APN 2.13-110-2_00 PARCEL SIZE 102. LAND USE APPLICATION # <br />04-10. <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />NON-REFUNDABLE PERMIT <br />JOB ADDRESS 0 <br />CROSS STREET <br />OWNER <br />OwNER ADDRESS 17 \111 „Si& <br />CONTRACTOR WWII c Dr al tv <br /> <br />Cot/TRACTOR ADDRESS III fl pirA - <br /> <br />1%. C-57 WELL DRILLING LICENSE NUMBER 4Uqt,023.- • <br />PERFORATION CONTRACTOR <br />EXPIRATION DATE <br />PHONE <br />PERFORATION CONTRACTOR ADDRESS CITY/STATE/ZIP <br />C-57 Well Drilling License Number Expiration Date <br />Bureau of Alcohol, Tobacco and Firearms - Users of High Explosives License Number Expiration Date <br />CHP Hazardous Material Transportation for Explosives License Number Expiration Date <br />San Joaquin County Sheriff-Coroner Explosives Application and Permit License Number Expiration Date <br />California Occupational Safety Health - Blaster License Number Expiration Date <br />(1.1. • <br />W0. -• P <br />PHONE <br />crrasTATElz, 1.0ArOv Gok ?ti <br />PHONE 1..7,-kct2.03 <br />crryisTATErzip modtirno. GOt c,rii <br />REASON FOR DESTRUCTION 3ry 0 Replacement Well 0 Caved In 0 Pit Well y,,.41nactive CI Test Hole <br />Detected/Suspected Well Water Contaminant(s) <br />Adjacent property with contamination (Address) <br />Known Soil/Water contaminants at adjacent property <br />EXISTING WELL CONSTRUCTION DETALS <br />Well Log copy attached 0 Yes No 1 ,.. <br />Well Conductor Casing 0 Yes No <br />Well Casing Diameter g inches <br />DESTRUCTION SPECIFICATION <br />Sealing Material from 0 ft bgs to 2,g ft bgs Filler Material <br />Well casing to be perforated by one of the following methods: from <br /> <br />ft and/or <br />ft 0 without projectile <br />ft 0 without projectile <br />Mills Knife Number of cuts every <br />Explosives El Detonating cord 0 with projectiles every <br />0 Detonating cord and boosters 0 with projectiles every <br />0 Open Bottom ‘ril., Gravel Pack o Uncesed 0 Other <br />Grout Seal 0 No 0 Yes ft below ground surface (bgs) Hole Diameter inches <br />7 <br />Depth of Conduct r Casing ft \ <br />ft Depth of Casing <br />s Diameter of Conductor Casing inches <br />Total Depth ft Depth to Water ft bgs <br />PAYMENT; <br />from ft bgs teR_____ELVEfrigs <br />ft bgs to bgs <br />2022 <br />„N JOAQUIN COUNTY, <br />LNVIRONNIENTAL <br />II AL Di DEPARTMENT <br />)cflentonite 0 Other <br />peguting <br /> <br />Material Neat Cement (94 lb bag/5-6 gal water) Sand Cement sack mix/7 gal water <br />Bentonite (20% solids) Manufacturer Spec % solids % Name Specs on File <br />Placement Method ii Pumped Li Free Fall Other <br />Seal Completion Ll Complete with Mushroom Cap -3- ft bgs <br />MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS, CALL (209) 953-7697 FOR INSPECTIONS <br />COMMENTS <br />PE SC <br />info <br />Received Checid# <br />Cash <br />Amount <br />Remitted Date invoice Permit/ <br />Service Request # <br /># Well ID# <br />Codes <br />'13 13 i C• 1 <br />BA A I <br />Ft14 \J16& 1 1 (15- k '4A 'Ti- INIP 00 LI 2-1-11 <br />A .1 _ - - 1 n <br />WELL DESTRUCTION PERMIT <br />EHD 43-08 <br />11/23/21 <br />Specs Submitted <br />Complete to Existing Surface Pad :SS:413(143V 311S