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HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS Tine MO. OW V DAT144.111:14_ e kirAC-t-1 M P Area / Tre?[ Employee Oa AS Application Accepted By ,P-7- DEPARTMENT USE ON/Y Destruction Inspection By k • COMMENTS (-1 0 CA Date 6/6" Date VC)/ WELL DESTRUCTION PERMIT PUBLIC WATER SYSTEM 0 Yee Ohio SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPT 1868 East Hazelton Avenue -STOCKTON CA 95205-6232 • (209)468-3420 NON-REFUNDABLE PE ....... ,........., ......../ s-erk inio,Cl. I IVN CArirMa 1 TEAR I-ROM IJATE ISSUED Joe ADDRESS -1 35- I ar,v)-1- Li n t RAg- crraw Tear Lk C-A, cS 3 c Li t Csosa 97ReE7 Chri Y1 Ra. APN ,g13 01-0'4 1:1 PARCEL SIZE i 3 LAND USE APPLICATION I OWNER L- I f T..,1 C1v..71 :0 Liivilted R-; ;ne,•:.;1, .p PHONE OwNER ADDRESS i 3/7 Mc /chi Ry A.J.z .$te je oo crryisTATErh, Dc))4; i -f)r 75-.620 ‘27 CONTRACTOR I-; eAm c." 1)r ; kl ;66\ PHONE cli6- 'Pit-3 - CONTRACTOR ADDRESS PO OVA. 9C155-"ci- crrosTATEmp SCLC re, YY1 OA 4C CA 9 SY VI # C-57 WELL DRILUNG LICENSE NUMBER VC, (3 2 C 2- EXPIRATION DATE PERFORATION CONTRACTOR NI! Akt II ELKS, tAlL It SCIIIn't P., LI-C. PHONE cm, -16 i —.. 2-7-4 PERFORATION CONTRACTOR ADDRESS Cl 510 I'lajty YLA4,11 FAA 13 ii-7,01 crrasTA-rezip en.krtesc.`,LIA, CA 133( Z. 0 C-57 Well Drilling License Numbefr4 ram Expiration Date Bureau of Alcohol, Tobacco end Firearms - Users of High Explosives License Number -CA- 0.: . Expiration Date CHP Hazardous Material Transportation fcc Explosives License Number ' ' rI • /I-Expiration Date San Joaquin County Sheriff-Coroner Explosives Application and Permit License Number 1- • ' Expiration Date 1 ; ; v , California Occupational Safety Health - Blaster License Number , 7 ) I Expiration Date 1 REASON FOR DEITRUCTIVI 0 Dry 0 Replacement Wel 0 Caved In 0 Pit Well Inactive 0 Test Hole Detected / Suspected Well Water Contamlnant(s) Adjacent property with contamination (Address) Known Soil / Water contaminants at adjacent property gstST1NO WELL CONSTRUCTION Drr,siV (3 Open Bottom 0 Gravel Pack 0 Uncased 0 Other Well Log copy attached 0 Yes No Grout Seal 0 No 0 Yes ft below ground surface (bgs) Hole Diameter i, Inches Well Conductor Casing 0 Yes 0 No Depth of Conductor Casing ft bps Diameter of Conductor Casing Inches h Well Casing Diameter c„ Inches Total Depth fp i ft Depth to Water 13 ft Depth of Casing ft bgs DESTRUCTION SPECIFICATION Sealing Material from Et 1 ft bps to ft bps Filler Material from It bps to ft bps Well casing to be perforateti by ono of the followino methods; 64-44, Ai from (4 I ft trgs to ac, ft bgs 0 Mills Knife Number of cuts every ft and / or -Detonating 13--Exploalves le cord 0 with projectiles every ft (sr-Without projectile 0 Detonating cord and boosters 0 with projectiles every ft 0 without projectile 0 Other Sealing Material Neat Cement (94 lb bag / 5-6 gal water) Sand Cement ic. 3 sack mix 17 gal water Bentonite Pellets Bentonite (20% solids ufacturer Spec % solids % Name Specs on File Specs Submitted Placement Method Free Fall Other Seal Completion Complete hroom Cap ie fl bps Complete to Existing Surface Pad THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION LAWS. PE Codes SC Info Received py. Chock* "Cash Amount Remitted Data Permit/ Service Request A Invoice a Well ID* 4 p3 16 i zifflf- i/jst___ 4 ici§ lv12,1 vs/POI)L17 On END 43-08 revised 4114/18 /2' t,376 WELL DESTRUCTION PERMIT