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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 GALL N8 y53 -f VVI rOK INsrfeclIONS uArll«o I W EAR rtcvM LPAIC -WOucu <br />JOB ADDRESS F. <br />CIr1rmpffiar&hi <br />�] <br />CROSS STREET APN fi _ <br />PARCEL Silm ILAJID USE APi+LlCA7tON <br />rh <br />OWNER <br />PHONE �ni1N%yJ <br />OWNER ADDRESS 1 <br />r,Z�l/AID <br />CITY/STATE/ZIP'.lMA-Y. (A <br />CONTRACTORMkhr:)- U <br />PHONE <br />ComTjjjRACTOR ADDRESS 1A <br />CRY/STATFJZ P <br />C-57 WELL DRILLNG LICENSe NUYBER <br />EXPIRATION DATE O <br />PERFORATION CONTRACTOR <br />PHM <br />PERFORATION CONTRACTOR ADDRESS <br />C rYISTATE/Z1P <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 p Replacement Well p Caved In ❑ Pit Well O Inactive ❑ Test Hole <br />Well WaW Cwrtaminant(s) <br />Adoewd property with wnta rnirodon (Address) <br />Known SodlWater contaminants at adjacent property <br />E=TNG WELL CONSTRUCTM DETAILS ❑ open Bottom Gravel Pack ❑ Uncased O Other <br />Well Log copy attached O Yes No Grout Seal O No O Yes <br />It below ground surface (bgs) Hole Diameter_____, inches <br />Well Conductor Casing ❑ Yes ❑ No Depth of Condu or Casing <br />ft bgs Diameter of Conductor Casing __ inches <br />Well Casing Diameter �� inches Total Depth I ft Depth to Water ft Depth of Casing ft bgs <br />DESTRUCTION SPECIFICATION <br />Sealing Material from ft bgs to __ft bgs Finer Material <br />from ft bgs to b s <br />Wen casing to be eQ__rforated by one of the fo6wina methods: <br />from ft bgs to c <br />❑ Mills Knife Number of cuts every ft and/or <br />❑ Explosives ❑ Detonating cord ❑ with projectiles every <br />ft ❑ without projectile <br />APR <br />O Odler O Detonating cord and boosters ❑ with projectiles every <br />ft ❑ without projectile <br />?Q <br />Palle giling Material Neat Cement (94 /b ba95-6 gal water) , Sand Cement <br />� <br />N O <br />sack ndx!! gal water h,�q T"40, <br />x Bentonke (20% s) Manufacturer Spec % solids % Name <br />Specs on File � <br />Other TMF!• <br />Placement Method Pumped U Free a l <br />Seal Completion o plate with Mushroom Cap ft bgs 2 Complete to Existing Surface Pad <br />MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS, CALL (209) 953-7697 FOR INSPECTIONS <br />DEPARTMENT USE ONY <br />Application Accepted By l� Date I / �') Area y /��� <br />Destruction Inspection By Date Employee IDk A (7 <br />CAMMFNTS <br />T <br />Yn <br />r <br />N y <br />PE <br />Codes <br />Sc Received <br />Into <br />CheCkIll <br />Cash <br />Amount Pa"Permit/ Invoice 0 Well ID# <br />Remitted Servi tR <br />LI <br />Qt.. 0 <br />t4 I 11 111 <br />EHD43-08�L �� / 6 �V �� WELL DESTRUCTION PERAAIT <br />/��/p.� / <br />11/23/21 l L�� T� ` <br />