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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 C�/—�jCITY/ZIP <br />fe—Af� <br />Invoice # Well ID# <br />CROSS STREET V (�� APN r3� 3 ° �a 8 <br />PARCEL SIZEq•a5LAND USE APPLICATION # <br />OWNER G012 <br />G Z <br />ENVIRONMENTAL <br />"Mm, In Lir-FARTMENT <br />OWNER ADDRESS lifCnY/STATE/ZIPq_ <br />A�i7z <br />CONTRACTOR L' <br />PHONE / �l Z/n <br />CONTRACTOR ADDRESS f7 <br />CITY/STATE/ZIP <br />C-57 WELL DRILLING LICENSE NUMBER/jJ (1 <br />EXPIRATION DATE <br />PERFORATION CONTRACTOR <br />PHONE <br />PERFORATION CONTRACTOR ADDRESS <br />CITY/STATE/ZIP <br />❑ C-57 Well Drilling <br />License Number Expiration Date <br />❑ Bureau 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 Sheriff -Coroner Explosives Application and Permit <br />License Number Expiration Date <br />❑ California Occupational Safety Health - Blaster <br />License Number Expiration Date <br />REASON FOR DESTRUCTION ❑ Dry ❑ Replacement Well Caved In ❑ Pit Well ❑ Inactive ❑ Test Hole <br />Detected/Suspected Well Water Contaminant(s) A&2L7 <br />AZLL�� <br />Adjacent property with contamination (Address) <br />Known Soil/Water contaminants at adjacent property <br />EXISTING WELL CONSTRUCTION DETAILS ❑ Open Bottom ❑ Gravel Pack ❑ Uncased ❑ Other <br />Well Log copy attached ❑ Yes ❑ No Grout Seal ❑ No ❑ Yes <br />ft below ground surface (bgs) Hole Diameter <br />inches <br />Well Conductor Casing ❑ Yes ❑ No Depth of Conductor Casing <br />ft bgs Diameter of Conductor Casing <br />inches <br />Well Casing Diameterinches Total Depth 97�1-ft Depth to Water ft Depth of Casing <br />ft bgs <br />DESTRUCTION SPECIFICATION <br />Sealing Material from ft bgs to ft bgs Filler Material <br />from ft bgs to <br />ft bgs <br />Well casing to be perforated by one of the following methods: <br />from ft bgs to ft bgs <br />❑ Mills Knife Number of cuts every ft and/or <br />❑ Explosives ❑ Detonating cord ❑ with projectiles every <br />ft ❑ without projectile <br />❑ Detonating cord and boosters ❑ with projectiles every <br />ft ❑ without projectile <br />❑ Other <br />Sealing Material Neat Cement (94 /b bag/5-6 gal water% Sand Cement <br />/ _ sack mix/7 gal water ❑ Bentonite <br />Pellets /V <br />❑ Bentonite (20% solids) ❑ Manufacturer Spec % solids % Name <br />❑ Specs on File ❑ Specs Submitted <br />Placement Method 0 Pumped ❑ Free Fall ❑ <br />3 <br />Other <br />Seal Completion >f Complete with Mushroom Cap ft bgs <br />❑ Complete to Existing Surface Pad <br />MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS, CALL (209) 953-7697 FOR INSPECTIONS <br />DEPARTMENT USE ONLYL/l <br />Application Accepted By L Date Area ]]/ <br />Destruction Inspection By Date Employee ID# Ff4l n k <br />COMMENTS >t'stI vC}lo+n 5t Well enc/er perms i viPOO')3s8SVJe11 roll,PSecj vgti, e <br />� <br />PAYMENT- <br />RECEIVED <br />A <br />PE Sc <br />Received Check#/ Amount to Permit/ <br />Invoice # Well ID# <br />Codes Info <br />By sh Remitted Service Request # <br />3) 3 6 <br />G Z <br />ENVIRONMENTAL <br />"Mm, In Lir-FARTMENT <br />EHD 43-08 WELL DESTRUCTION PERMIT <br />11/23/21 <br />