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:SS3210(1V 11.1S 022 <br />WELL DESTRUCTION PERMIT <br />PUBLIC WATER SYSTEM 0 Yes 1S4LVo <br />1868 East Hazelton Avenue - STOCKTON CA 95205 - (209)468-3420 <br />EXPIRES 1 YEAR FROM DATE ISSUED <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />NON-REFUNDABLE PERMIT CALL (209) 953-7697 FOR INSPECTIONS <br />JOB ADDRESS <br />CROSS STREET kY-04.60Sel 1F-4 AN 110 040 PARCEL SIZEAOt 'LAND USE APPLICATION # <br />ADDRESS_____________________________ <br />CROSS can a IC/ PHONE <br />OWNER ADDRESS 13 Irsi• ,,Ste,Umit- Pia Cm/STATE/ZIP \/-0,00 <br />PHONE cal• <br />)k C-57 WELL DRILLING tfll OW 2-2- LICENSE NUMBER <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 />ID Pit Well )14 Inactive <br />Detected/Suspected Well Water Contaminant(s) <br />Adjacent property with contamination (Address) <br /> <br />Known SoiVWater contaminants at adjacent property <br /> <br />CI Open Bottom 1k. Gravel Pack 0 Uncased 0 Other <br />Grout Seal 0 No 0 Yes ft below ground surface (bgs) Hole Diameter inches <br />Depth of Conductor Casing ft bgs Diameter of Conductor Casing inches <br />Total Depth ()CI ft Depth to Water ft Depth of Casing ft bgs <br />EXISTING WEU. CONSTRUCTION DETAILS <br />Well Log copy attached 0 Yes It No <br />Well Conductor Casing 0 Yes No <br />Well Casing Diameter kg inches <br />DESTRUCTION SPECIFICATION <br />PA ylVIE <br />Sealing Material from 0 ft bgs to 09 ft bgs Filler Material from ft bgs to R5 .1511/ <br />Well casing to be perforated by one of the folkwiinci methods: from ft bgs to <br />Mills Knife Number of cuts every it and/or <br />Explosives 0 Detonating cord 0 with projectiles every ft 0 without projectile <br />0 Detonating cord and boosters 0 with projectiles every ft 0 without projectile <br />LI Other <br />Sealing Material Neat Cement (94 lb bag/5-6 gal water). Sand Cement sack mix/7 gal water )(Bentonite <br />Pellets <br />Bentonite (20% solids) .. Manufacturer Spec % solids % Name ; : Specs on File Specs Submitted <br />Placement Method li Pumped ii Free Falli <br /> <br />Other <br />Seal Completion CI 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 ONIr Y ; <br />Application Accepted By Date q/478/14i2 <br />Destruction Inspection By / <br />ik ''_) CK, Date <br />COMMENTS <br /> <br />Area 3/Z1, +1p <br />Employee ID# <br /> <br />paracno fadt Crry/Zrp 1 <br />OWNER <br />ADDRESS IN ii1R-6ff <br />tmAcitiiiS OtillIV. <br />CONTRACTOR <br />CONTRACTOR <br />PERFORAPON CONTRACTOR <br />PERFORATION CONTRACTOR ADDRESS <br />crryisTATEmp mo ct-o ook <br />0 4. 017.-77 EXPIRATION DATE <br />PHONE <br />CITY/STATE/ZIP <br />REASON FOR DESTRUCTION -)ry ID Replacement Well El Caved In D Test Hole <br />ePAY 02 <br />1 AlN jT°H4 <br />N VIRONMEN TA <br />RCTOm TV <br />NT <br />PE <br />Codes <br />SC <br />Info <br />Received Check*/ <br />, Cash <br />Amount <br />Remitted <br />1 l Cg-- <br />Date <br />d 1P1'i <br />Permit/ <br />Service Request * <br /> _5 t P Do432 <br />invoice it Well ID* <br />LI373 1(• I <br />AIN: jt <br />• <br />- , . . / - ----, -1/. /..": ._ . , / _ ---, — --II <br />WELL DESTRUCTION PERMIT <br />EHD 43-08 <br />11/23/21