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WELL DESTRUCTION PERMIT <br />PUBLIC WATER SYSTEM ❑ Yes ❑ No <br />SAN JoAouei 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 I 0 CrrY/7JP v v <br />CROSS STREET V APN !N� V��i 01 D PARCEL SUE LAND SE`APPLICATION 0 <br />OWNER1wrR&VW PHONE // 1/� ' "�^1(�� /� `ill <br />OWNER ADDRESS / CrTYISTATE/ZJP i J )y1loy t%v�/ •'I ✓ 1' <br />CONTRACTOR unmm V - PHONE %J I <br />CONTRACTOR ADDRESS M BIM I sy r t/l • /�., CITY/STATEMP "I 11 Lf <br />3, C-57 WELL DRILLING UCENSE NUMBER_ �U Q)W L7/ EXPIRAnom DATE ' �O <br />PERFORATION CONTRACTOR PHONE <br />PERFORATION CONTRACTOR ADDRESS CrTYISTATE2IP <br />❑ C-57 Well Drilling License Number Expiration Date <br />❑ Bureau of Alcohol, Tobacco and Firearms - 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 Dl�r:r <br />REAsoN FOR DESTRUCTION Dry ❑ Replacement Well ❑ Caved In <br />❑ Pit Well ❑ Inactive t c:/Vi <br />Detected/Suspected Well Wafer Contaminants) <br />/VF <br />Adjacent property with contamination (Address) <br />U411 A <br />Known Soil/Water contaminants at adjacent property <br />EXISTING WELL CONSTRUCTION DETAILS ❑ Open Bottom Gravel Pads ❑ Uncased ❑ Otter FNV1 INC T' <br />Well Log copy attached ❑ Yes ❑ No Grout Seal ❑ No Yes ft below ground surface (bgs) Hole Dlame N DE24 P3;&iies, <br />Well Conductor Casing ❑ Yes ❑ No Depth of Con sing ft Diameter of Conductor Casing 'Al ,,r <br />Ca <br />Well Casing Diameter_ inches Total Depth It Depth to Water R Depth of Casing It bgs <br />DESTRUCTION SPECEWATION <br />Sealing Material from ft bgs to W71 ft bgs Filler Material <br />from ft bgs to ft bgs <br />Well Casing to be perforated by.one of the foll Inas methods: <br />from ft bgs to ft bgs <br />❑ Mills Knife Number of alts every ft and/or <br />❑ Explosives ❑ Detonating cord ❑ with projectiles every <br />it ❑ without projectile <br />❑ Detonating Cord and boosters ❑ with projectiles every <br />ft ❑ without projectile <br />❑ Other <br />Poll aling Material i Neat Cement (94 /b baW5-6 gat wateJ) _i Sand Cement <br />sack mix17 gal water Bentonite <br />Bentontte (20% solids) _: Manufacturer Spec % solids % Name Specs on Fie Specs Submitted <br />PI cement Method Pumped U Free Fall L, Other <br />Seal Completion .or ete with Mushroom Cap _�_ ft bgs Complete to Existing Surface Pad <br />MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS, CALL (209) 953-7697 FOR INSPECTIONS <br />DEPARTMENT USE <br />Application Accepted By �� /� Date_ <br />Destruction Inspection By Date <br />ONLYo1 <br />50 v7 Area <br />�'Z r I.A 1--17. C( Z mploYee li # � �7 <br />COMMENTS <br />EHD43-08��� WELLDESTRUCT(ON PERMIT <br />11f23121 i, ! / CO (p <br />