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�++ 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 3285 Cherokee Road CITY/ZIP Stockton 95205 m <br /> CROSS STREET Newton Road APN 092 169 V7 PARCEL SIZE { USE APPLICATION# <br /> OWNE �,,/' ,7 1, PHONE <br /> OWNER ADDRES O�AJ /�+ CITY/$TATE/ZIP <br /> CONTRACTOR Terracon Consultants, nc./Neil O. Anderson PHONE 209-367-3701 <br /> CONTRACTOR ADDRESS 902 Industrial Way CITY/STATE/ZIP Lodi, CA 95240 <br /> 04 C-57 WELL DRILLING LICENSE NUMBER 669004 EXPIRATION DATE 5/31/2023 <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 Conducctorr ng ft bgs Diameter of Conductor Casing inches <br /> y <br /> Well Casing Diameter inches Total DeptNnd7" / Depth to Water ft Depth of Casin ft s <br /> DESTRUCTION SPECIFICATION �ECEIV,�� <br /> Sealing Material from ft bgs to ft bgs Filler Material from ft bg <br /> Well casing to be perforated by one of the following methods: from ft bgs to b <br /> ❑ Mills Knife Number of cuts every ft and/or 2022 <br /> ❑ Explosives ❑ Detonating cord ❑ with projectiles every ft ❑ without projectile JOAQUIN COUNTY <br /> ❑ Detonating cord and boosters ❑ with projectiles everyft ❑ without project&M/IRONMENTAL <br /> 11 Other HEALTH DEPARTMENT <br /> Sealing Material Neat Cement(94 lb bag/5-6 gal water) Sand Cement sack mix/7 gal water Bentonite <br /> 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 /> MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS, CALL(209)953-7697 FOR INSPECTIONS <br /> DEPARTMENT USE ONLY <br /> Application Accepted By Date 9 2 Z Area <br /> Destruction Inspection By Date 1,24x— Z� Employee ID# <br /> CO ENTS G!i! O G✓e <br /> CO <br /> c/ / o <br /> PE SC Received Check#/ Amount Date Permit/ Invoice# Well ID# <br /> Codes Info I By p ash Remitted Service Re uest# <br /> 37 (,P/' l�s l Z z N \ <br /> EHD SGL `�L(� WELL DESTRUCTION PERMIT <br /> 11123121/21 ///�GGi��� G � Z <br />