Laserfiche WebLink
WELL DESTRUCTION PERMIT- - <br /> PUBLIC WATl7t SYS'iE1N ❑Yes ❑No <br /> SAN JOAOUN COUNTY ENVIIRONMENTAL HEALTH DEPARTMENT 1868 East Hazelton Avenue-STOCKTON CA 95205 -(209)4683420 <br /> NON-REFUNDABLE PERMIT CALL209 853-7697 FOR INSPECTIONS FD(PIRES.1 YEAR FROM DATE ISSUED <br /> JOB ADDREss CrrY/ZP Vi <br /> a <br /> (;8083 V1 145 <br /> APN - PARCEL Sad LAN1D�l'{`s APkIICATION� d <br /> O� ib <br /> _Ulm PHONE 1 J1! <br /> OWNER ADDRESS L Crrr/STATEILP <br /> CONTRACTOR Pliol <br /> CONTRACTOR ADorrEas CrrY/STATEr� <br /> C57 WELL Dm-uN'G LICENSE N111R Z EmmTm DATE <br /> P TION CONTRACTOR -. PHOIM; <br /> PERFORATION CONTRACTOR ADDRESS CITY/STATL P <br /> ❑ C57 Well Drilling Lxense 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 /> Fog DESTRuCTym Dry ❑ Replacement Well ❑ Caved In ❑ Pit Well ❑ Inactive ❑ Test Hole <br /> Detected/Suspected Well W minarrt(s) <br /> Adjacent property with contamination(Address) <br /> Known Soil/Water contaminants at adjacent property <br /> EXISTING WELL CONSTRucnos DETAas '❑ Open bottomRes <br /> avel Pads 11Uncased 13 Other <br /> Wed Log copy attached ❑ Yes ❑ No (trout Seal 13 No -ft below ground surface(bgs) Hole Diameter inches <br /> Wed Conductor Casing Yes ❑ No Depth ofCordkxAw <br /> Casing ft Diameter of Conductor Casing inches <br /> Well Casing Diameter inches Total DepthIUD_ft Depth to Water 44 IV ft Depth of Casing ft bgs <br /> DEmuum SPECIFlCmm Pq <br /> Sealing Material from�_ft tags to Jwft bgs Filler Material- from ft bgs to A#E T <br /> Well casing to be by one of the following methods: from 9 bgs to E/C1 ' I <br /> O Mills Knife _ Number of carts every ft and/or V <br /> _ I D <br /> ❑ Explosives ❑ Detonating cord ❑ with projectiles every—__ ft ❑ without projectile <br /> Detonating cord and boosters ❑ with projectiles everyft ❑ without projectile NOVn 16 �O <br /> ❑ Other _ _ SAN,/O <br /> sling Material ❑ Neat Cement(94 Ib bagy5-6 gat water)_: Sand Cement sack rnW7 gal water NU/N CO <br /> Peu NEALTN MENTA IVTy <br /> Bentonite(20 ids) Manufacturer Spec%solids % Name Specs on File i i Specs P�j NT <br /> Plecat»ent Method , th <br /> Pumped it Free Fall f -i Oer <br /> Seal Completion 11 &Mpiete with Mushroom Cap ft bgs a Complete to Existing Surface Pad <br /> MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS,CALL{209)953-7697 FOR INSPECTIONS <br /> DEPARTMENT USE ONLY 'L 9 <br /> Appl�pn Amsted By Date �Z Area `7 <br /> Destruction Inspection By. Data i ^)XA Employee ID# /111.7 <br /> COMMENTS <br /> PE SIC Cash ftled g <br /> Received Amount Dab pw Invoice g Well 100CaNs Irrfo <br /> W P , 0 +4-07 0 <br /> ;HrD�43-0lr �� r �� � I WELL UESTRUC7ION PEKMIT <br />