Laserfiche WebLink
WELL DESTRUC'T'ION PERMIT <br />PUBIdC WATERSYSIEM ❑ Ye ❑ No <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304E WEBER AVE 3 -FL- STOCKTON CA 95202 - (209)468-3420 <br />NEIN-RFFITNnARI.F PFRMIT CALL /7X01 Q4i-7607 FnR FNSPFITVINC FYPIRFS 1 VFAR Funic IIATrr IScnun <br />JOB ADDRESS v' <br />irrvizu, t••) ` i CA • \ 7 Z - 'TV <br />G ,,O..%eeW`` ,,. <br />CROSSSTREEET ST• pPN <br />PARCEL SIZE _LAND USE APPLICATION# <br />�kK*ZA�• <br />OWNER C. k \ OF Lop l <br />PHONE 20CI - '2,3 (a bOO�e,) 4 - 2Z&Iv <br />OWNER ADDRESS SZ I 1/I) • PI ► VT- <br />CITV/STATE/T.IP L'� D ` CA • _ Qi S z I <br />CONTRACTOR V• W. DRIu-ilsG <br />PRONE I - LI ' <br />CONTRACTOR ADDRESS —% ! <br />� t 7 Y LQ <br />CITV/STATE/LIP -L <br />XC-57 WELL DRILLING LICENSENUMaER_7 �� <br />EXPIRATIONDA'FE <br />PERFORATION CONTRACTOR <br />PHONE <br />PERFORATION CONTRACTOR ADDRESS <br />CITV/ST.1TErLtPCw <br />X, C-57 Well Drilling <br />License Number �sS�70 -! Expiration Date L �� <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 Contamitum al <br />Adjacent property with contamination (Address) <br />Known Soil /Water contaminants at adjacent pmperty <br />EXISTING WELL CONSTRUCTION DETAILS ❑ Open Bottom ❑ Gravel <br />Pack ❑ Uncased ❑ (hher _ <br />Well Log copy attached )KY. ❑ No Grout Seal ❑ No ❑ Ye. <br />__ _ tl below ground surface tbgs) Hole Diameter inehea <br />Well Conductor Casing ❑ Yes ❑ No Depth of Conductor Casing ____ <br />11 bgs Diameter of Conductor Casing inches <br />Well Casing Diameter ____inches Total Depth -11 Depth to Water____ _,fl Depth of Casing ft bgs <br />DESTRUCTION SPECIFICATION // / <br />Scaling Material from ft bgs Filler Muterhil /4a { t,-r.=%Mf C�1 from 5)Jit bgs to it hip <br />Well casing to be perforated by one of the followine methods: from <br />ft bgs to It bgs <br />❑ Mills Knife Number of cuts every ft and / or <br />❑ Explosives ❑ Detonatingcord ❑ with projectiles every <br />ft ❑ without projectile <br />❑ Detonating cord and boosters ❑ with projectiles every <br />ft ❑ without projectile <br />❑ Other <br />Sealing Material Nest Cement (94 lb hag/S-6 gal %vier) ❑ Sand Cement <br />sack mix / 7 gal water ❑ Benfoolte Pellets <br />❑ Bentonite (2 /e milds) ❑ Manufacturer Spec % solids % Name <br />❑ Specs on File ❑ Specs Submitted <br />Placement Melhod� Pumped ❑ Free Fall ❑ Outer <br />Seal Completion Complete with Mushroom Cap ft bgs ❑ Complete to Existing Surface Pad <br />I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br />JOAQUIN COUNTY ORDINANCES. STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE 1S <br />CURRENT AND ACTIVE WITH TRE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br />WORKERS COMPENSATION LAWS i <br />NOTICE REQUIRED WR INSPECTIONS <br />Application Accepted By <br />n <br />` <br />PAR MENT <br />_ _ <br />USE ONLY i <br />Date -1 (I . 2"0'{` <br />Ama , <br />Destruction Inspection By <br />_ <br />Dace (:h Ab_Q <br />CO. MMES <br />7S� <br />.at.t_,. <br />kpo 7n <br />_ o u_ r <br />-t c.t )(� i <br />PE SC Received Cbxd& Amount Date Permit/ Invoke # Well 1D# <br />Codes Info BV "I-cuo Remitted Service Request # <br />FIm434Lma Wen De w. P ­ <br />V2712005 <br />