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WELL DESTRUCTION PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />NON-REFUNDABLE PERMIT CALL <br />PUBLIC WATER SYSTEM ❑ Yes jdo <br />1868 East Hazelton Avenue -STOCKTON CA 95205 - (209) 468-3420 <br />953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS /Z KZ -3- " - _ (� ^ CITY/ZIP �J [���� ` <br />CROSS STREET y+/� V y� / w APNy lq )T ' PARCEL SIZE I ' iAND USE APPLICATION # <br />OWNER r/L /yS_ �/J� PHONE <br />1 t <br />OWNER ADDRESS CITY/STATE/ZIP— <br />CONTRACTOR !/ PHONE <br />CONTRACTOR ADDRESS CITY/STATE/ZIP <br />❑ C-57 WELL DRILLING LICENSE NUMBER �(O f7 $�h EXPIRATION DATE 7 Z <br />PERFORATION CONTRACTOR 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 />REASON FOR DESTRUCTION Pr Dry ❑ Replacement Well ❑ Caved In ❑ Pit Well nrinactive ❑ Test Y� <br />Detected/Suspected Well Water Contaminant(s) 1 <br />Adjacent property with contamination (Address) /1 <br />Known Soil/Water contaminants at adjacent property <br />EXISTING WELL CONSTRUCTION DETAILS ❑ Open Bottom ❑ Gravel Pack ❑ Uncased ❑ Other AN k <br />Well Log copy attached ❑ Yes ❑ No Grout Seal ❑ No ❑ Yes ft below ground surface (bgs) Hole DiamAs�N <br />Well Conductor Casing ❑ Yes ❑ No Depth of Conductor Casing ft bgs Diameter of Conductor Casing <br />Well Casing Diameter �� inches Total Depth —I&Lft Depth to Water- Depth of Casing ft <br />DESTRUCTION SPECIFICATION <br />Sealing Material from ft bgs to ft bgs Filler Material from ft bgs to it bgs <br />Well casing to be perforated by one of the following methods: from ft bgs to ft bgs <br />❑ Mills Knife Number of cuts every ft and/or <br />❑ Explosives ❑ Detonating cord ❑ with projectiles everyft ❑ without projectile <br />❑ Detonating cord and boosters ❑ with projectiles every ft ❑ without projectile <br />❑ Other <br />Sealing Material Neat Cement (94 Ib bag/5-6 gal water) ❑ Sand Cement sack mix/7 gal waterBentonite �� <br />Pellets <br />Bentonite (20% solids) Manufacturer Spec % solids % Name ❑ Specs on File ❑ Specs Submitted <br />Placement Method Pumped Free Fall Other W)!L- <br />Seal Completion Complete with Mushroom Cap ft bgs -1 Complete to Existing Surface Pad <br />MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS, CALL (209) 953-7697 FOR INSPECTIONS <br />D PARTMENT USE ONLY Lf C <br />Application Accepted By Date Area I ( <br />Destruction inspection B Date - <br />2 Z- Employee ID# <br />COMMENTS Wet 4 i <br />PE SC <br />Codes I o <br />Received Ch <br />By -C-a-sIT <br />Amount Date Permit/ Invoice # Well ID# <br />Remitted Service Request # <br />EHD 43-08 WELL DESTRUCTION PERMIT <br />11/23/21 <br />