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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPT NON-REFUNDABLE PERMIT CALL 209 953-7607 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED 1868 East Hazelton Avenue - STOCKTON CA 95205-6232 - (209) 468-3420 DATE , (MU 48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS CONTRACTORS SIGNATURE TITLE AA ('Ii 2. Employee ID# Date El-10 43-08 rovise8 4/14/18 WELL DESTRUCTION PERMIT WELL DESTRUCTION PERMIT PUBLJC WATER SYSTEM 0 Yes No JON ADDRESS i &t.. a Cirvar 774. Ike,' CA 91 -3c ./ - , N ;213 0701*. ... r- 3 7 i CROSS STREET 4 PARCEL ota•-•° LANO USE APPLICATION # OWNER Lit- 1. tiCiti :Li P. in L. irA 11, rin ft 101.1p PHONE ri OwNER ADDRESS 017 inLk;n ?Ivy ye Ste 11 t' cm/s-TATE/zip bri 1 ic,.( Vr 7)(:),..,: CONTRACTOR hiASSlea el Chlkelf PHONE 7/4 -- 31( 3 - 3 L 74 CONTRACTOR ADDRESS Pk) 134 II' PT2ii.345-5--- CITYISTATEIZTP_411k reAWK1F4e 4:4 V-54•74 - C-57 WELL DRILUNG LICENSE NUMBER gOt ree 2- EXPIRATION DATE Z3LI/Sti PERFORATION CONTRACTOR mcinitait.'s 441/ciez"..efe.e • L-I.-C PHONE ,,i4T 7' /- .57,2-2- PERFORATION CONTRACTOR ADDRESS CI 5 3 0 Ati (41,41,r) a s?. 8 1,3Y9 CITY/STATE/ZIP 15'r-A wsfiii CA i..3.4 /2— jel oi , . 0 C-57 Well Drilling License Number e eVezzdlfri*. Expiration Date Bureau of Alcohol, Tobacco and Firearms - Users of High Explosives License Number -c11 05 , .1 Expiration Date (./foi / CHP Hazardous Matenal Transportation for Explosives License Numbert3O Ti 1 r Expiration Date San Joaqur County Sheriff-Coroner Explosives Application and Permit License Number Al ( -O.: Expiration Date California Occupational Safety Health - Blaster License Number s's IF .7.) ' Expiration Date REASON FOR DESTRUCTION 0 Dry 0 Replacement Welt 0 Caved In El Pit Well Inactive 0 Test Hole Detected / Suspected Well Water Contamlnant(s) Adjacent property with contamination (Address) Known Soil / Wa'ar contaminants at adjacent property EXISTING WELL CONSTRUCTION DETAILS ...., 0 Open Bottom 0 Gravel Pack 0 Uncased 0 Other Well Log copy attached 0 Yes 0/1No Grout Seal 0 No 0 Yes ft below ground surface (togs) Hole Diameter inches Well Conductor Casing 0 Yes 0 No Depth of Conductor Casing ft bgs Diameter of Conductor Casing inches Well Casing Diameter , Inches Total Depth 1,-.1 ft Depth to Water / in ft Depth of Casing ft bgs DESTRUCTION SPECTFICATION Sealing Material from .. ft bgs to ft bgs Filler Material front ft bgs to ft bgs L., Well casing to be perforated by One of the followinQ methods', from 4 '? ft bgs to 7.-0 rt bgs 0 Mills Knife Number of cuts every It and I or liVgcplosives GrF/etonating cord 0 with projectiles every ft tie-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 /t'. ,s, sack mix I 7 gal water Bentonite Pellets Bentonite (20% solids acturer Spec % solids % Name Specs on File Specs Submitted Placement Method Free Fall , Other Seal Completion Complete with Mushroom Cap 41. ft bgs Complete to Existing Surface Pad I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND 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. Sc A--msce-itc1) 51Te DEPARTMENT USE ONLY Application Accepted By ...,...-!:-_—/__-rj_....- Date VC-'ii ) Area 5irrt , Gy Destruction Inspection By COMMENTS PE Codes SC info . Received Checiai sh Amount Remitted i Date PerinW invoice # Service Request If Well ID" 113 73 16,i c/P2)-- Fi 5,0-- 0 ficiS- 1E111 ‘PIP03-12. I