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T <br /> 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 CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS,? /^� CITY/ZIP <br /> V <br /> CROSS STREET �J Z APN VI) 000 e PARCEL SIZE 50 LAND USE <br /> APPLICATION# <br /> OWNER PHONE <br /> OWNER ADDRESS !� CITY/STATE/ZIP ( //���� <br /> CONTRACTOR — PHONEra11/�J !!2 — Z <br /> .4/ — /V- <br /> CONTRACTOR ADDRESS CITY/STATE/ZIP '7' <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 <br /> REASON FOR DESTRUCTION Dry ❑ Replacement Well ❑ Caved In ❑ Pit Well ❑ Inactive <br /> Detected/Suspected Well W ter Contaminant(s) �/En <br /> Adjacent property with contamination(Address) A(1r, r 7��� <br /> Known Soil/Water contaminants at adjacent property �.. �R[U% <br /> EXISTING WELL CONSTRUCTION DETAILS ❑ Open Bottom ❑ Gravel Pack ❑ Uncased ❑ Ot* ZIT/ROgI SU'Vry <br /> Well Log copy attached ❑ Yes ❑ No Grout Seal ❑ No ❑ Yes ft below ground surface(bgs) Hole Diameter EP!4RTMg rhTTes <br /> Well Conductor Casing ❑ Yes ❑ No Depth of Conductor Casing ft bgs Diameter of Conductor Casing incfies <br /> Well Casing Diameter�inches Total Depth " Depth to Water /-3.5 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 Ib bag/5-6 gal water) 1 Sand Cement sack mixll gal water A oBentonite <br /> Pellets <br /> Bentonite(20%solids) Manufacturer Spec%solids % Name - Specs on File Specs Submitted <br /> Placement Method Pumped /V Free Fall Otheron V <br /> Seal Completion Complete with Mushroom Cap ft bgs Complete to Existing Surface Pad 54A*3 <br /> MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS, CALL(209)953-7697 FOR INSPECTIONS <br /> DEPARTMENT USE ON Y <br /> qlqqApplication Accepted By Date a ? Area C / ` <br /> Destruction Inspection By Date Employee ID# f f q" V <br /> COMMENTS SIc+b <br /> PE SC Received CChack#KAmount Date Permit/ Invoice# Well ID# <br /> Codes Info B as Remitted S rvice Request#? <br /> H3(4 OC-,O 1 <br /> EHD43-O8 WELL DESTRUCTION PERMIT <br /> 11/23/21 <br />