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WELL DESTRUCTION PERMIT gA4',t <br />PSM WAI es No <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE 3RD FL- STOCKTON CA 95202 - (209) <br />NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES I YEAR FROM DAT=P- <br />JOBADDRESS CITV/Z� �. �V) <br />CROSS STREET LDw1' APN_PARCELSIE~�LAND USE APPLICATION <br />OWNER n 51 PHONE <br />N <br />PHONE Q60 <br />OWNER ADDRESS CITY/STATE/ZlP <br />CONTRACTOR AM PHONE ((R 2f S 9- ' AA <br />CONTRACTOR ADDRESS CITY/STATE/ZEP " f%T �SJSI <br />❑ C-57 WELL DRILLING LICENSE NUa1BER EXPIRATION DATE ? Q <br />PERFORATION CONTRACTOR All Di�.�`4Ri/fl0 Z)'�9"7Ai-(s�em � PHONE ��pp lJ Cs),/D� <br />PERFORATION CONTRACTOR ADDRESS 5 K,/(/EL reLYiD CITY/STATE/ZIP THIO 1APA. 64 JTI <br />0 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 ❑ Rep agement Well ❑ Caved I ❑ Pit WeII IV Inactive [3Test Hole <br />Detected / Suspected Well Water Conlaminant(s) e1. r i i84 %.r—p%A <br />Adjacent property with contamination (Address) <br />Known Soil / Water contaminants at adjacent property <br />EXISTING WELL CONSTRUCTION DETAILS ❑ Open Bottom ❑ Gravel Pack ❑ Uncased 9 Other <br />Well Log copy attached 12 Yes ❑ No Grout Seal ❑ No 0 Yes il—ft below ground surface (bgs) Hole Diameter inches <br />Well Conductor Casing ❑ Yes 51 No Depth of Conductor Casing ft bgs Diameter of Conductor Casing inches <br />Well Casing Diameter R, inches Total Depth A Depth to Waterfv ds ft Depth of Casing ft bgs <br />DESTRUCTION SPECIFICATION . 1 <br />Sealing Material from _ _ ft bgs to _ _ A bgs Filler Material N� (-(yr((=,/Uf from _0 ft bgs to qr ft bgs <br />Well "sing to be perforated by one of the following methods: from 0 ft bgs to 90 ft bgs <br />❑ Mills Knife Number of cuts every ft and / or <br />❑ Explosives ❑ Detonating cord ❑ with projectiles everyft ❑ without projectile <br />d ❑ Detonatin cord and boost with proje�ti{ps ev ft ❑ without projectile <br />!.' Other l <br />Sealing Material NO Neat Cement (94 lb hag/S-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 11 Pumped ❑ Free Fall ❑ Other <br />Seal Completion Id Complete with Mushroom Cap ft bgs 13 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 />MINTMUNI 24 HOUR ADVANCE NOTICE REQUIRED FOR TNSPE MONS <br />DEPARTMENT USE ONL ' Q/ / <br />Application Accepted By "1 1 I Date 3 0� Area <br />Destruction Inspection By Date Employee IDN <br />COMMENTS <br />%';WENT /LALTH <br />PE <br />SC Received <br />Info By <br />CheckN/ <br />Cash <br />Amount <br />Remitted <br />Permit/ <br />Invoice N Well IDN <br />Service Req <br />rvuest N <br />Oz <br />01 <br />O <br />E.FD) 43.02-008 <br />ta,a6a5 <br />owc,ion Pertnil <br />%';WENT /LALTH <br />