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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 />JOBADDRESS 2-1zOI 61 / 6(TJLfS /G(C� CITYIZIP /� / <br />CROSS STREET�jl/w1� ,�©//%'j�/� /��)APN ,�DS%-�%Z�%Z�) --D 7 PARCEL SIZE <br />/D USE APPLICATION # <br />OWNER �L✓�/rrJ/✓ Cf,{/��K-S S%�i- — " - PHONE <br />OWNER ADDRESS—,P—. Qc ag7 ?2 CITY/STATE/ZIP <br />CONTRACTOR /I�j�,j JN S 'rt-f'C� PHONE �c, 31-3� z 1 do t' <br />CONTRACTOR ADDRESS I3 S t;0ir fIC/ CITY/STATE/ZIP �ckfoei �� _lJ�15- <br />C-57 WELL DRILLING LICENSE NUMBER -1 [� G� EXPIRATION DATE I 3 <br />PERFORATION CONTRACTOR PHONE <br />PERFORATION CONTRACTOR ADDRESS <br />CITY/STATE/ZIP <br />Invoice # <br />❑ C-57 Well Drilling <br />License Number <br />Expiration Date <br />❑ Bureau of Alcohol, Tobacco and Firearms - Users of High Explosives License Number <br />Expiration Date <br />❑ CHP Hazardous Material Transportation for Explosives <br />License Number <br />Expiration Date <br />❑ San Joaquin County Sheriff -Coroner Explosives Application and Permit License Number <br />Expiration Date <br />❑ California Occupational Safety Health - Blaster <br />License Number <br />Expiration Date <br />REASON FOR DESTRUCTION JV Dry ❑ Replacement Well <br />❑ Caved In ❑ Pit Well ❑ <br />Inactive ❑ Test Hole <br />Detected/Suspected Well Water Contaminant(s) <br />Adjacent property with contamination (Address) <br />Known Soil/Water contaminants at adjacent property <br />_ <br />EXISTING WELL CONSTRUCTION DETAILS ❑ Open Bottom <br />❑ Gravel Pack ❑ Uncased <br />❑ Other ^-v�E <br />Well Log copy attached ❑ Yes ❑ No Grout Seal ❑ No <br />❑ Yes ft below ground surface (bgs) <br />Hole DiametepPT_A_/ ss <br />Well Conductor Casing ❑ Yes ❑ No Depth of Conductor Casing <br />-- ngE-V G 1 Y EJ <br />ft bgs Diameter of Conductor Cas i <br />Well Casing Diameter _ [P inches Total Depth _ 161 ` t <br />Depth to Water 7407—ft <br />Depth of Casings <br />A A W T 9"9 <br />Sealing Material from ft bgs to ft bgs Filler Material <br />Well casing to be perforated by one of the following methods: <br />❑ Mills Knife Number of cuts every .- ft and/or __ <br />❑ Explosives ❑ Detonating cord ❑ with projectiles every <br />❑ Detonating cord and boosters ❑ with projectiles every <br />❑ Other _. <br />Sealing Material Neat Cement (94 lb bag/5-6 gal water) Sand Cement <br />Pellets <br />from ft (JOAQU1N.COUNT' <br />from ft bgs to ENVIRCFNTAL <br />HEALI H DEPARTMENT <br />ft ❑ without projectile <br />ft ❑ without projectile <br />3/,5 <br />sack mix/7 gal water j✓ Bentonite <br />Bentonite (20% solids) Manufacturer Spec % solids % Name Specs on File Specs Submitted <br />Placement Method Pumped )/ Free Fall Other <br />Seal Completion Complete with Mushroom Cap ft bgs Complete to Existing Surface Pad -rZW 3C40"Ibc <br />MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS, CALL (209) 953-7697 FOR INSPECTIONS <br />%J DEPARTMENT USE O N L Y <br />Application Accepted By Z/1 f✓' Date S10.2 .7 2 Area <br />Destruction Inspection By (!' j l Date Employee ID# <br />COMMENTS 0fl,J Well �(� i7Y►s�1yc4rdi up (le( SPGWe;4r. pe(�+^�i� <br />T <br />K - <br />PE Sc Receive Check#/ <br />Codes Info A loy Cash <br />Amount at Permit/ <br />Remitted Service Re uest # <br />Invoice # <br />Well ID# <br />3(b 060 v <br />)sa 2 3 <br />EHD 43-08 WELL DESTRUCTION PERMIT <br />11/23/21 <br />