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WELL DESTRUCTION PERMIT <br />PUBLIC WATER SYSTEM ❑ Yes ❑ No <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1888 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 />JOY ADDRESS <br />CROSS STREET <br />OWNER <br />SUE Z SUE USE APPLICATION <br />CON�TJRACTOR ADDRESS _" 1 ii t V V r Z <br />Lj C-57 WELL DRIWNG LICENSE NWBER I II1�Jlil� EXPIRATION DATE T <br />"/ <br />PERFORA\TION CONTRACTOR <br />PHONE <br />PERFORATION CONTRACTOR ADORE SS <br />CRYISTATEIZIP <br />❑ C-57 Well Drilling <br />License Number <br />Expiration Date <br />❑ Bureau of AkAhol, Tobacco and Firearms - Users of High Explosives <br />License Number <br />Expiration Date <br />❑ CHP Hazardous Material Transportation for Explosives <br />License Number <br />Explratwn Date <br />❑ San Joaquin County Shaffl-Caroler Explosives Application and Permit <br />License Number <br />Expiration Date <br />❑ CaMor►ia Occupational Safety Heatih - Blaster <br />License Number <br />Expiration Date <br />REA$ON FOR Dwitu� II Dry ❑ Replacernent Well ❑ Caved In <br />Detected/Suspected Well WaU r Corltarnlnant(s) <br />Adjacent Property with contamination (Address) <br />Known Soil/Water contaminants at adjacent property <br />❑ Pit Web ❑ Inactive O <br />ExlsTutG WELL CONSTRUCT CON DETAR S ❑ Open Bottorm Gravel Pads ❑ Uncased ❑ Other NF " m RDA, <br />Well Log copy attached ❑ Yes ❑ No Grout Seal ❑ No Yes ft below ground surface (bgs) Hole Diarrletar OF <br />Well Conductor Casing ❑ ftYes ❑ No Depth of C -Casing ft bas. Dtwneter of Conductor Casing t <br />Well Casing DiameterX—Y inches Total Depth I p - _ ft Depth to Wetar_ ft Depth of Casing R bgs <br />DESTRUCTION 3PEC14CATMN <br />Sealing Material fromft bgs to _ft bgs FIOer Mats" from ft bgs to R bgs <br />Well casing to be perforated by from R bgs to ft bgs <br />❑ Mills KnHe Number of arts every ft and/or <br />❑ Explosives c3 Detonating cord ❑ with projectiles every It [3 without projectile <br />❑ Detonating Cord and boosters ❑ with projectiles every ft ❑ without projectile <br />❑ Outer <br />Ing --1 r 1 Neat Cement (941b h-5-6 gal water) Sand Cement-sackixll rngal water Bentonite <br />Pell <br />Bentonite ( ids) ' 1 Mam fairer Spec % solids % Name <br />P cement Y Pooped u F all G Other <br />Seal Comptetl Complete with Mushroan Cap ft bgs G Complete to Existing Surface Pad <br />Specs on File Specs Submitted <br />MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS. CALL (209) 953-7697 FOR INSPECTIONS <br />DEPARTMENT USE ONli,Y <br />Application Accepted By t-� Date 3l o2oa Area <br />Destruction Inspection By Date -6 SGPT 7,022 Employee ID# <br />COMMENTS �j f � uric. r i L t r �r e�Abf)oc��e4+e•vn ! cli a h' C�� �T FI eS ths. <br />EHD 11R312i n �/�� �4 72 - WELL DESTRUCTION PERMIT <br />