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EMAILED t�Zg 3 ss WELL DESTRUCTION PERMIT r IF PUBLIC WATER SYSTEM ❑Yes JK No SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 East Hazelton Avenue-STOCKTON CA 95205 - (209)468-3420 NON-REFUNDABLE PERMIT ` CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED rIVY JOB ADDRESS IM 7 1 N CrfY21PI DON « °I Ci3 ISV T ch1 Via, 2-Qt-U 0-n50 CROSS STREET APN PARCEL SIZE• LAQN�DI(US)E APPLICATION# OWNER N �Nkl, PHONE t W'LJ I I li+ V OWNER ADDRESS r 1 CITY/STATE/LP CONTRACTOR AM 1 1 \ 7PHONE Sy -f--'1OGL(b /`/� x—7 CONTRACTOR ADDRESS 1 Y CITY/STATE/ZIP I V I�O(U �D i r1(Of kC-57 WELL DRILLING LICENSE NUMBER Z EXPIRATION DATE '"j 30. ZOZ 9 PERFORATION CONTRACTOR PHONE PERFORATION CONTRACTOR ADDRESS CrrY/STATE/ZIP ❑ C-57 Well Drilling License Number Expiration Date ❑ Bureau of Alcohol,Tobacco and Firearms-Users of High Explosives License Number Expiration Date D ❑ CHP Hazardous Material Transportation for Explosives License Number Expiration Date ❑ San Joaquin County Sheriff-Coroner Explosives Application and Permit License Number Expiration &s/ [ 023 ❑ California Occupational Safety Health-Blaster License Number Expiration WA/1,vN qU REASON FOR DESTRUCTION Dry ❑ Replacement Well ❑ Caved in ❑ Pit Well ❑ Inactive ❑ Test Ho�EPq�7- ANT y Detected/Suspected Well Water ontaminant(s) ENT Adjacent property with contamination(Address) Known SoitNVater contaminants at adjacent property_ EXISTING WELL CONSTRUCTION DETAILS ❑ Open Bottom Gravel Pack ❑ Uncased ❑ Other Well Log copy attached ❑ Yes .X No Grout Seal ❑ No ❑ Yes _ft below ground surface(bgs) Hole Diameter inches Well Conductor Casing.E3 Yes ❑ No Depth of Cond ctor Casing ft Diameter of Conductor Casing __inches Well Casing Diameter II inches Total Depth ft Depth to Water _ft Depth of Casing_ _ft bgs DESTRUCTION SPECIFICATION Sealing Material from �ft bgs toM N1 ft bgs Filler Material, _-__ from ft bgs to _ft bgs Well casing to be perforated by one of the following methods: from It bgs to ft bgs ❑ Mills Knife Number of cuts every ____._._ft and/or__ ❑ Explosives ❑ Detonating cord ❑ with projectiles every it ❑ without projectile ❑ Detonating cord and boosters ❑ with projectiles every__ it ❑ without projectile ❑ Other_ Sealing Material Neat Cement(941b bag15-6 gal water) Sand Cement sack mix17 gal water Bentonite Pellets Bentonite(20%solids) Manufacturer Spec%solids % Name Specs on File Specs Submitted Placement Method Pumped Free Fall Other Seal Completion Complete with Mushroom Cap ft bgs Complete to Existing Surface Pad MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS, CALL(209)953-7697 FOR INSPECTIONS EPARTM ENT USE ONLY Application Accepted By Date Area Destruction Inspection By Lt Date 1 Employee ID# COMMENTS PE SC Received Check#/ Amount Date Pertniti Invoice# Well ID# Codes Info By Cash Remitted Service Requgst.119- 1-5 J EHD 43-08 / ;�- /' � // / /SU / WELL DESTRUCTION PERMIT 11!23121