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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 LUy U06-1OUI I -OR INSNECIION5 Ir_ArIMrw I TC/JAK rKUM�jURI C Iooucu <br />JOB ADDRESS - CITY/ZIP <br />" - <br />-�] �7 <br />CROSS S Er 1 y APN /r PARCEL SIZE <br />LAND USE APPLICATION li <br />OWNER MA"lip1 l PHONE <br />.j} <br />OWNER ADDREss3 �1 CITY/STATE/LP <br />r <br />�7 <br />CONTRACTOR e7 %NN PHONE 1- <br />2AU <br />CONTRACTOR ADDRESSIla CITYISTATERIPWAM".. <br />n <br />(AJ q`r ?rjl <br />L`( C-57 WELL DRILLING LICENSE NumBERAiWk— EXPIRATION DATE <br />04-N-477 <br />PERFORATION CONTRACTOR PHONE <br />PERFORATION CONTRACTOR ADDRESS CrrYISTATEMP <br />❑ C-57 Well Drilling 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 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 License Number <br />Expiration Date <br />[3 Replacement Well El Caved In ❑ Pit Well <br />REASON FOR DESTRUCTION �:�amlnant(s) <br />Inactive 171Te i <br />Detected/Suspected Weli W <br />' <br />Adjacent property with contamination (Address) <br />Known Soil/Water contaminants at adjacent property <br />-- -- -----SAA, -- <br />EXISTING WELL CONSTRUCTION DgM ❑ Open Bottom Gravel Pads ❑ Uncased ❑ Other �i&N�/ v/N <br />Wel! Log copy attached ❑ Yes No Grout Seal ❑ No Yes _ ft below ground surface (bgs) Hole Diameter N Dt7 rd /-�/ <br />inc 5' <br />Well Conductor Casing ❑ es ❑ No Depth of Cond o• rasing ft s I Diameter <br />IJC <br />of Conductor Casing <br />Depth of Casing ft bgs <br />Well Casing Diameter inches Total Depth Depth to Water�ft <br />_ <br />DESTRUCTION SPECIFICATION <br />1,)0 <br />ft bgs to bgs <br />Sealing Material from ft bgs to ft bgs Filler Material --- <br />—from_ _ft <br />Well casing to be perforated by one of the following methods: from <br />ft bgs to ft bgs <br />nd/or_❑ <br />❑ MIAs Knife Number of cuts every ___,ft and/or--- <br />•Explosives ❑ Detonating cord ❑ with projectiles everyft <br />❑ without projectile <br />❑ Detonating cord and boosters ❑ with projectiles every _ ft <br />❑ without projectile <br />❑ Other <br />Sealing Material Neat Cement (94 lb bag/5-6 gal wafer)' Sand Cement sack mixl7 gal water Bentonite <br />Pellets <br />Bentonite (2D% solids) - Manufacturer Spec % solids_/o Name <br />Specs on File Specs Submitted <br />Placement Method I I Pumped U Free Fall , I - Other <br />Seal Completion A_ Complete 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 ONLY Date F, 0 / J <br />�/ .7 Area <br />Application Accepted By <br />Destruction Inspection By Date T� V �� ALL Employee ID# <br />COMMENTSVI P f vt t - j C> SJ �:� C; (i' �' / m i <br />pa ' -_M' <br />PE SC �Recelved <br />Codes Info B <br />43'73 A-,1 <br />EHD 43-08 <br />11/23/21 <br />ieddll Amount Date <br />;ash Remitted <br />PermW Invoice # Well ID# <br />; 7 <br />Service Re ue t _ <br />WELL DESTRUCTION PERMIT <br />