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WELL DESTRUCTION PERMIT <br /> PUBLIC WATER SYSTEM Yes No <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPT 1868 East Hazelton Avenue - STOCKTON CA 95205-6232 - (209) 468-3420 <br />NON-REFUNDABLE PERMIT CALL (209) 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />EHD 43-08 WELL DESTRUCTION PERMIT <br />revised 4/14/18 SITE ADDRESS: JOB ADDRESS CITY/ZIP <br />CROSS STREET APN PARCEL SIZE LAND USE APPLICATION # <br />OWNER PHONE <br />OWNER ADDRESS CITY/STATE/ZIP <br />CONTRACTOR PHONE <br />CONTRACTOR ADDRESS CITY/STATE/ZIP <br /> C-57 WELL DRILLING LICENSE NUMBER 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) <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___________inches Total Depth _________ft Depth to Water___________ft 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 every _________ft † without projectile <br />† Detonating cord and boosters † with projectiles every _________ft † without projectile <br />† Other <br />Sealing Material Neat Cement (94 lb bag / 5-6 gal water) Sand Cement _________sack mix / 7 gal water Bentonite Pellets <br /> Bentonite (20% solids) Manufacturer Spec % solids_____% Name_____________________ Specs on File Specs Submitted <br />Placement Method Pumped Free Fall Other ______ __________________________________ <br /> Seal Completion Complete with Mushroom Cap _________________ ft bgs Complete to Existing Surface Pad <br />I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br />JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br />CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br />WORKERS COMPENSATION LAWS. <br />MINIMUM 48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br />CONTRACTORS SIGNATURE TITLE DATE <br />DEPARTMENT USE ONLY <br />Application Accepted By ____________________________________________ Date________________________ Area ________________________ <br />Destruction Inspection By ___________________________________________ Date________________________ Employee ID# __________________ <br />COMMENTS <br />PE <br />Codes <br />SC <br />Info <br />Received <br />By <br />Check#/ <br />Cash <br />Amount <br />Remitted Date Permit/ <br />Service Request # Invoice # Well ID# <br />Operations Manager 3/2/2022