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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 32 3herokee Road CITY/ZIP Stockton 95205 y <br /> CROSS STREET Newton Road APN / rPARCEL SIZEta✓ / • I6W USE APPLICATION # <br /> OWNER / �L 07 / PHONE <br /> OWNER ADDRESS OVvBflog /' CITYISTATE/ZIP <br /> Terracon Consultants inc . / Neil _ �4 ��i�' <br /> CONTRACTOR O Anderson PHONE 209 367 3701 <br /> CONTRACTOR ADDRESS 902 Industrial Way CITYISTATE /ZIP Lodi , CA 95240 <br /> R 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 Conductor . Casing ft bgs Diameter of Conductor Casing inches <br /> Well Casing Diameter inches Total Depth ft Depth to Water ft Depth of Casin ft b s <br /> DESTRUCTION SPECIFICATION <br /> Sealing Material from ft bgs to ft bgs Filler Material from ft bg ECEIVV "PP . <br /> Well casing to be perforated by one of the following methods : from ft bgs to bas <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 every ft El without projecti�NVIRONMENTAL <br /> El Other HEALTH DEPARTMENT <br /> Sealing Material Neat Cement (94 Ib bag/5-6 gal water) ❑ Sand Cement sack mix/7 gal water ❑ entonite <br /> Pellets <br /> Bentonite (20 % solids ) ❑ Manufacturer Spec % solids % Name ❑ Specs on File D. Specs Submitted <br /> Placement Method ❑ Pumped I 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 Z � Q 2 Z Area <br /> Destruction Inspection By Date l2w� x � Z� Employee ID# <br /> CO ENTS G!/JO ALJ rxr�z <br /> a/ �e <br /> P � <br /> ey4l rAo �• fir-_ <br /> PE SC Received Check#/ Amount Permit/ <br /> Codes Info B Cash Remitted Date Service Request # Invoice # Well ID# <br /> 37 /eel /ys � ? 2 z \ <br /> EHD 08 ( 1 2 6 WELL DESTRUCTION PERMIT <br /> 11 / 23/ 2/ 2 1 v L- G 7 <br />