Laserfiche WebLink
WELL DESTRUCTION PERMIT <br />PUBLIC WATER SYSTEM ❑ Yes ❑ No <br />SAN JOAom COUNTY ENV1RONMENTAL 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 Cr" Zip ✓ � <br />tMmND <br />te} — n <br />��USE A)PP/►LICAT1oN II <br />CROSS STREET APN �`rr7 1 D" V PARCEL <br />/ <br />OWNERAY I PHONE �� -q-r3 - 1 U2 e)'n��} <br />OWI ER ADDA£jq <br />SS CfTYiSTATEaV 1 1_2 N COU 15- Yf W <br />CONTRACTOR;kill I <br />PHONE <br />CONTRACTORSS crrY7srATF1ZP , GN! �� 3s 7 <br />���EXPIIRATION <br />C-57DR$11NG LICENSE Numem DATE�� � <br />WELL <br />PERFORATION CONTRACTOR PHONE <br />PERFORATION CONTRACTOR ADDRESS CrrY1STATEi1P <br />❑ C-57 Well Drilling License Number F_,cpiration Date <br />❑ Bureau of Akohol. Tobacco andFaearms- 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 DEsTRucTTDN Dry ❑ Replacement Well ❑ Caved In ❑ Pit Well ❑ Inactive ❑ Test Hole <br />Detected/Suspected Well W c«rtaminant(s) <br />Adjacent property with contamination (Address) <br />Known SoillWater contaminants at adjacent property ._ -- -- - -- --- <br />EX15TOIG WELL CONSTM)cnm DETAILS ❑ Open Bottom ❑ Gravel Pads ❑ Uncased ❑ Other PA ' <br />Wer Log copy attached ❑ Yes ❑ No Grout Seal 13 No ❑ Yes ft below ground surface (logs) Hole Diame inches <br />Wan Conductor Casing Yes ❑ No Depth of ConductorCasing ft Diameter of Conductor ng Wlc hes <br />�'AlSl�7lLtn�gft bgs <br />Depth <br />Well Casing Dimneter inches Total Depth ft Depth to Water' fl of <br />1 11 1111t91! -rV- <br />ENVIRON <br />DESTRUCTION SPWMATIQ �{ EgLT H DEPART MEN j <br />Sealing Material from L ft bgs to ff logs Filler Material irnm_ it logs to ft logs <br />J <br />Well casing to be Perforated by one of the following methods: from ft bgs to ft bgs <br />❑ Mills Knife Number of Ons every _ft and/or _ _ -- <br />_____ <br />❑ Explosives ❑ Detonating cord ❑ with protectiles every_ ft ❑ without projectile <br />❑ Detonating cord and boosters ❑ with projectiles every - - ft ❑ without projectile <br />❑ Other <br />Ing Material f7 Neat Cement (941b bag/5-6 gat water) ❑ Sand sack Cement sarnm17 gal water Bentonite <br />Pell <br />Bentonite (20% solids) � Manufacturer Spec % solids % Name i i Specs on File - Specs Submitted <br />Placement M n Pumped Free Fall IJ Other <br />ft bgs :i Complete to Existing Surface Pad <br />Seal Completion Complete with Mushroom Cap <br />MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS, CALL (209) 953-7697 FOR INSPECTIONS <br />DEPARTMENT USE ONLY <br />Application Accepted By Z_'L Date 7Area <br />�y�/ �� G <br />DestnxtionJnSpebtion gy Date ��i Z�ZZ Employee ID# <br />PAP <br />—� <br />'5E�AAWME=WM=Wa Me <br />EHD 43.08 of 115-& If- '-_714L [q 2- 2-- WELL DESTRUCTION PERMIT <br />11/23/21 <br />