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WELL DESTRUCTION PERMIT <br />. SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />NON-REFUNDABLE PERMIT CALL <br />JOB ADDRESS_ <br />CROSS STREET <br />OWNER <br />PUBUC WATER SYSTEM ❑ Yes OQ N. <br />1868 East Hazelton Avenue - STOCKTON CA 95205 - (209) 468-3420 <br />953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />CITYIZIP <br />N aQ V P, U®' 1 PARCEL SIZ/alk4AND USE APPLICATION # <br />y <br />9. <br />OWNER ADDRESS .J,030 hadd 9d <br />CITY/STATE/ZIP <br />Amount <br />Remitted <br />i Date j Invoice # <br />i Service Request # <br />CONTRACTOR LJ ,, dr o,, I i Nn L� <br />PHONE b L'� ^? r �j -a' <br />CONTR TOR ADDRESS 2,,-"C3 <br />'1C-57 WELL DRILLING LICENSE NUMBER Lk 72 - `V, <br />EXPIRATION DATE <br />PERFORATION CONTRACTOR C0 Ol C.r% 1N (. <br />PHONE_ �� 6 J, _ <br />6S o, <br />� <br />PERFORATION CONTRACTOR ADDRESS �y 4 4 �] 0.n 4 ig • <br />CITYISTATE/ZIP ,S D c� lei <br />C l <br />❑ C-57 Well Drilling <br />License Number � 3y �) g <br />E pirali Date <br />13Bureau of Alcohol Tobacco and Firearms - Users of High Explosives <br />License Number <br />Expirat Date <br />❑ CHP Hazardous Material Transportation for Explosives <br />License Number _d O b S 1-7Expiration <br />Date <br />❑ San Joaquin County Sheriff -Coroner Explosives Application and Pearl <br />License Number 37 6 t 1 <br />Expiration Date <br />❑ Califomia Occupational Safety Health - Blaster <br />License Number 1 <br />Expiration Date -4-0�5 <br />REASON FOR DESTRUCTION ❑ Dry ❑ Replacement Well Jes' Caved In ❑ Pit Well ❑ Inactive ❑ Test Hole <br />Detected,/Suspected Well Water Contaminant(s) <br />Adjacent property With contamination (Address) _ <br />Known SoibWater contaminants at adjacent property <br />EXISTING WELL CONSTRUCTION DETAILS ❑ Open Bottom ❑ Gravel Pack ❑ Uncased ❑ Other <br />Well Log copy attached ❑ Yes ❑ No Grout Seal 11 No ❑ Yes ft below ground surface (bgs) Hole Diameter __ incites <br />Well Conductor Casing ❑ Yes ❑ No Depth of Conductor Casing _ ft bgs Diameter of Conductor Casing _ itches <br />Wall Casing Diameter inches Total Depth ft Depth to Water ft Depth of Casing ft bgs <br />;y InVV.IVn Vr GVlrl\. /�IIVIV <br />Sealing Material from /qn. f-'bgs to ft bgs Filler Material — from ft bgs to P <br />Well casing to be perforated by one of the following methods: _ from R bgs to CF 1 ' �` <br />L7 IIs Knife Number of cuts every ft and'or - _ / C6 <br />1 Explosives ❑ Detonating cord ❑ with projectiles every_ __ ft ❑ without projectile C <br />detonating cord and boosters ❑ With projectiles everyTff- ft ❑ without projectile O <br />❑ Other <br />Sealing Material Neat Cement (94 Ib baW5-6 gal water <br />Pellets <br />) Sand Cement !1_ sadtmib#gal water /YF �C4Ste �V/N ` 1 H �M CpV <br />Bentonite (20% solids) nufacturer Spec S. solids ° <br />Placement Method ' Pumped Free Fall <br />Seal Completion Complete with Mushroom Cap _ S- <br />- <br />Name Specs on File Specs 9, 7Z 7*Y <br />Other MF T <br />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 <br />Application Accepted Byr� Date do v�o� Area _q <br />w <br />o -- u. s --P ,uvn olr wniyt �n del_ 4 Date_ _ �.�� Empioyee 1D# -_A/('1_._ . <br />COMMENTS C: c MT m o, e Meta l? W 1;'k. NJ P; h t fa <br />S c I n tt�+ `' iz. 7 r, �bfi <br />r�t,'T'able „If`,FPT. !n, sack 1f f P <br />PE <br />Codes <br />SC Received <br />info B Check#/ <br />Cash <br />Amount <br />Remitted <br />i Date j Invoice # <br />i Service Request # <br />Well ID# <br />EMO 43-08 <br />11123121 WELL DESTRUCTION PERMIT <br />