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WELL DESTRUCTION PERMIT / PUBLIC WATER SYSTEM ❑ Yes )lo 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 EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS t //"/"o�y(jZ/ /� !/" /l/� / �Q�.J �J� CITY/ZIP r /0^0t 431 �- y--� ` MG 3� CROSS STREET LV, 5- 7— 1- /�4�9QC /��IsA�PN f � q��,�f�J /�� / rP�A�R�CEL SIZ�� LAND USE APPLICATION # OWNER Al A)r)� /�(1��/�iF- /�✓f- ~'_ HF' O %%t/�j%�%��J/�J OWNER ADDRESS / �`�� /d cJ�/ii/J�i/ff CITY/STATE/ZIP/�s�l�i��%�y L� CONTRACTOR /� /`'/C�,J'f/,/7�� I�1(//� •/"+tet�i�L- PHONEL CONTRACTOR ADDRESS 6! G O //�� al L E-_f%� /x(09' ( CITY/STATE/ZIP ❑ C-57 WELL DRILLING LICENSE NUMBER�t7 iJ l EXPIRATION DATE PERFORATION CONTRACTOR PHONE PERFORATION CONTRACTOR ADDRESS CITY/STATE/ZIP ❑ C-57 Well Drilling License Number Expiration Date ❑ Bureau of Alcohol, Tobacco and Firearms - Users of High Explosives License Number Expiration Date ❑ CHP Hazardous Material Transportation for Explosives License Number Expiration Date ❑ San Joaquin County Sheriff -Coroner Explosives Application and Permit License Number Expiration Date ❑ California Occupational Safety Health - Blaster License Number Expiration Date REASON FOR DESTRUCTION )PODry Replacement Well [:1Caved In ❑ Pit Well ❑ Inactive E]Test Hole Detected/Suspected Well Water Contaminant(s) Adjacent property with contamination (Address) Known Soil/Water contaminants at adjacent property EXISTING WELL CONSTRUCTION DETAILS W 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 MWEN Well Casing Diameter inches Total Depth —eft Depth to Waterft Depth of Casing DESTRUCTION SPECIFICATION Z- Nt ZL yy��pp�/ p Sealing Material from ft bgs to ft bgs Filler Material S �ft bgs to I�IH 1 1 fpbg�, Well casing to be perforated by one of the following methods: from ft bgs to bbc �s A-C.�UIN COL ❑ Mills Knife Number of cuts every ft and/or ENVIRONMENT) ❑ Explosives ❑ Detonating cord ❑ with projectiles everyft ❑ without projectile HEALTH DEPARTM ❑ Detonating cord and boosters ❑ with projectiles every ft ❑ without projectile ❑ Other Sealing Material Neat Cement (94 lb bag/5-6 gal water) Sand Cement sack mix/7 gal waterBentonite Pellets KV Bentonite (20% solids) Manufacturer Spec % solids % Name Specs on File Specs Submitted Placement Method Pumped IV Free Fall Other Seal Completion Complete with Mushroom Cap ft bgs Complete to Existing Surface Pad MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS, CALL (209) 953-7697 FOR INSPECTIONS SDEPARTMENT USE ONLY Application Accepted By Date `� ��Z7�— Area '3 A'� Destruction Inspection By Date Employee ID# COMMENTS -57• !Jp' 5-73 T PE Codes SC Info Received B Check#I ash Amount Remitted Dat Permit/ Service Request # Invoice # Well ID# Y373 i�/ EHD 43-08 WELL DESTRUCTION PERMIT 11/23/21