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!' <br />WELL DESTRUCTION PERMIT <br />PUBLIC WATER SYSTEM ❑ Yes W5% <br />1 <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 East Hazelton Avenue - STOCKTON CA 95205 - (209) 468-3420 <br />NON-RFFIINDABt_F PERMIT CALL 12091953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE IsstlFn <br />-i <br />JOB ADDRESS,L'j �s�, CITY/ZIP <br />CROSS STREET L APN / —314 60 PARCEL SIZE LAND USE APPLICATION # <br />OWNER /L /T �� ONE IVO /q � <br />OWNER ADDRESS Zi�7-4!3 CITY/STATE/ZIPV- <br />/ <br />CONTRACTOR . S �^ � PHONE_ -ZIV—: } <br />CONTRACTOR ADDRESS i!/ ' CITY/STATE/ZIP J '� <br />�n C-57 WELL DRILLING LICENSE NUMBER *6'1 EXPIRATION DATE / <br />PERFORATION CONTRACTOR PHONE <br />PERFORATION CONTRACTOR ADDRESS CITY/STATE/ZIP <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 Date <br />REASON FOR DESTRUCTION ❑ Dry ❑ Replacement Well ❑ Caved In ❑ Pit Well Inactive ❑ Test Hole <br />Detected/Suspected Well Water Contaminant(s) <br />Adjacent property with contamination (Address) ff <br />Known Soil/Water contaminants at adjacent property %�— <br />EXISTING WELL CONSTRUCTION DETAILS ❑ Open Bottom ❑ Gravel Pack ❑ Uncased ❑ Other <br />Well Log copy attached ❑ Yes ❑ No Grout Seal ❑ No ❑ Yes ft below ground surface (bgs) Hole Diameter inches <br />Well Conductor Casing ❑ Yes ❑ No Depth of Conductor Casing ft bgs Diameter of Conductor Casing inches <br />Well Casing Diameter�p k(inches Total Depth ft Depth to Water2mft Depth of Casing ft bgs <br />DESTRUCTION SPECIFICATION <br />Sealing Material from ft bgs to ft bgs Filler Material from ft bgs to ft bgs <br />Well casing to be perforated by one of the following methods: from ft bgs to ft bgs <br />❑ Mills Knife Number of cuts every ft and/or <br />❑ Explosives ❑ Detonating cord ❑ with projectiles everyft ❑ without projectile <br />❑ Detonating cord and boosters ❑ with projectiles everyft ❑ without projectile <br />❑ Other <br />Sealing Material ❑ Neat Cement (94 /b bag/5-6 gal water) ❑ Sand Cement sack mix/7 gal water )W Bentonite <br />Pellets <br />❑ Bentonite (20% solids) ❑ Manufacturer Spec % solids % Name Specs on File ❑ Specs Submitted <br />Placement Method ❑ Pumped ❑ Free Fall ❑ Other gqpg�E <br />Seal Completion A Complete with Mushroom Cap 3 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 ON Y_ <br />Application Accepted By 1 l Date_q Area 3 <br />Destruction Inspection By . Date l� (�i 1-7 Z Employee ID# <br />COMMENTS JC<,'rneh CIf' }�� tT Well. 620 rrn GT P l l 0 ! ' go.' <br />c vc bet-, e o rVsh <br />6* Ply cA 31 11 bass ^1 �Wl 04f .i W 4K -K 2-1J, bckslA_ � - /y L � <br />T <br />z <br />PE <br />Codes <br />SC <br />Info <br />Received qz&awip Amount Date Permit/ <br />By Cash Remitted Service Request # <br />Invoice # obi <br />X1 73 <br />10 <br />l�S� i 5 <br />VED <br />. — iV44 <br />EHD /21 $SMI 1�RMIT <br />11!23/21 u!� <br />�M`.x4a 1� <br />•&A� <br />