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WELL DESTRUCTION PERMIT <br />PUBLIC WATER SYSTEM ❑ Yes ❑ No <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 East Hazelton Avenue - STOCKTON CA 95205 - (209) 468-3420 <br />NON-REFUNDABLE PERMIT CALL (209) 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS <br />CmZP <br />CROSS STREET APP,a y S I a (� J a <br />��Q <br />PARCEL SRW' OO LAND USE APPLICATION S <br />OWNER <br />7 I� <br />OWNER ADDRESS 441 V VOLV1 MVN VA <br />CITY/STATErZP <br />CONTRACTOR S Ak i YO N A 10&. <br />PHONE '7,A <br />CONTRACTOR ADDRESS IQP(I&Lvg <br />t^ ^7 <br />CITY/STATEIZP <br />C-67 WELL DRILLING LICENSE NUMBER 1/1,Y <br />EXPIRATION DATEI—Ai O - 70 <br />PEI—RATION CONTRACTOR <br />PHONE <br />PER TION CONTRACTOR ADDRESS <br />CRY/STATE/ZP <br />G57 Well Drilling <br />License Number Expiration Date ' <br />Bure auau of Alcohol, Tobacco and Firearms - Users of High Explosives <br />License Number Expiration Date <br />❑ CHP Hazardous Material Transportation for Explosives <br />License Number Expiration Date <br />❑ San Joaquin County Shedff-Coroner Explosives Application and Permit <br />License Number ExDirafimjQate <br />' <br />❑ California Occupational Safety Health - Blaster <br />License Number Fri D <br />REASON FOR DESTRUCTION kDry Replacement Well ❑ Caved In ❑ Pit Well ❑ Inactive F^D <br />Detected/Suspected Well W Contain s) <br />C <br />Adjacent property with contamination (Address) <br />Known Soil/Water contaminants at adjacent property <br />SA Af <br />ilp <br />ElOSI>1Ni< _WE lNNNSTRUCTION DETAILS ❑ Open Bottom Gravel Pads LI Uncased O STN�/%IFNT"_1 i <br />Well Log copy atlached ❑ Yes ❑ No Grout Seal ❑ No ❑ Yes <br />R below ground surface (bgs) Hole Diameter <br />Wall Conductor Casing ❑ Yes ❑ No Depth of Conduc5LOr Casing <br />fl Disntvtar of Conductor Casing inches <br />Well Casing Diarw4sr irldles Total Depth V0 ft Depth to Water it Depth of Casing It bgs <br />DESTRUCTION SPECFICATION <br />Sealing Material from _ ______ It bgs to _ft bgs Filter Mabuial <br />from It bgs to ft bgs <br />Well casing to be perforated by one of thy fQNQWrm m0thods: <br />frau ft bgs to ft bgs <br />❑ Mills Knife Number of cuts every It and/or <br />❑ Explosives O Detonating cord ❑ with projectiles every <br />ft ❑ without projectile <br />❑ Detonating cord and boosters ❑ with projectiles every <br />It ❑ without projectile <br />❑ Otltar <br />POINVIngMaterial ❑ Nest Cement (941b bagi5-6 get water) li Sand Cement <br />sack rnbu7 gal water )(Bentonite <br />❑ BentonPoe (20% solids) G Manufacturer Spec % solids % Name <br />G Specs on File ❑ Specs Submitted <br />Placeffmd Medlod ❑ Pumped ❑ Free Fall I-, <br />Other <br />Seal Completion ❑ Complete with Mushroom Cap . :�? It bgs Complete to Existing Surface Pad <br />MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS, CALL (209) 953-7697 FOR INSPECTIONS <br />y DEPARTMENT USE ONLY <br />Application Accepted By �/� L Date -7/a ��aa Area S �% cl <br />Destruction inspection By Date Employee ID# <br />COMMENTS <br />Co7dE <br />SC Into Recelvad Clio/ <br />Amo—Remitted <br />Perm <br />Dab Seryl R W III <br />Invoice # Well too <br />7 I� <br />1 <br />/✓ <br />�il ! 1 f��� (r 5w i <br />EHD 43-08 n � � l —7� � WELL DESTRUCTION PERMIT <br />