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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 ADDRESSan-K CirrYIZIP rl 1701y. ca -1 l�;3,11 V' <br /> CROSS STREET APN PARCEL SIZE{{y* LAIN(D USE APPLK ATION# o <br /> OWNER V PHONE_�1!'J' I✓"l� ��{{ v <br /> OWNER ADDRESS L Z CITY/STATEIZIP �1 N <br /> CONTRACTOR /� Y XQ � r PHONE <br /> CONt ut TRACTOR ADDRESS {I 1 it V rQA _CtTY/$TATEOP 1 5 V i 7/\.1I lJ (�G�a 15 N7 <br /> G57 WELL DRILLING LICENSE NUYBER � �lI Z2 EXPRATION DATE /V �VL►� <br /> PERFORATION CONTRACTOR PHONE <br /> PERFORATION CONTRACTOR ADDRESS CITYISTATEIZIP <br /> ❑ C-57 Well Drilling License Number Expiration Date C <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 16 <br /> 6 <br /> ❑ San Joaquin County Sheriff-Coroner Explosives Application and Permit License Number Expiration Datg Sn,• �a2 <br /> ❑ California Occupational Safety Heafth-Blaster License Number Expiration Da Oq <br /> kjfv <br /> C <br /> REA30N FOR DESTRUCTION DryReplacement Well ❑ Caved In ❑ Pit Well ❑ Inactive ❑ Test H e h DEp/ NT,NTy <br /> Detected/Suspected Wall Water mina t(s) TMENT <br /> Adjacent property with contamination(Address) <br /> Known Soil/Water contaminants at adjacent property <br /> Ex18Tm WELL CONSTRUCTIQN DETAILS ❑ Open Bottom Gravel Pads ❑ Uncased ❑ Other <br /> Well Log copy attached ❑ Yes 01 No Grout Sell ❑ No ❑ Yes ft below ground surface(bgs) Hole Dlamete► inches <br /> Well Conductor Casing ❑ Yes ❑ No Depth of Condu Casing ft Diameter of Conductor Casing inches <br /> Wap Casing Diarrwter_ inches Total Depth ft Depth to Water �ft Depth of Casing ft bgs <br /> DESTRUCTION SPECWXATM <br /> Sealing Material from _ft bgs to 9 Filler Material from ft bgs to ft bgs <br /> Well casing to be p2dqEaW by ora of the eavinB methods: from ft bgs to ft bgs <br /> ❑ MIMs Knife Number of Cuts every ft and/or <br /> ❑ Explosives❑ Detonating card ❑ with projectiles everyft ❑ without projectile <br /> ❑ Detonating cord and boosters ❑ with projectiles everyIt ❑ without projectile <br /> ❑ t)Itrer <br /> PelletgsamIng Material Neat Commit(94 tb bag-5-6 11 gat water} Sand Cement Sack mbV7 gal water Bentonite <br /> Bentonite(20X.solkis) I Manufacturer Spec%solids % Name Specs on File Specs Submitted <br /> Placement Method I I Pumped U Free Fall Pr Other <br /> Seal Completion t i Complete with Mushroom Cap R bgs Complete to Existing Surface Pad <br /> MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS, CALL(209)953-7697 FOR INSPECTIONS <br /> l DEPARTMENT USE f 1Vt Y a <br /> Application Accepted By L L Date � a Area -I /� <br /> Destruction Inspection By Date I `J Employee 10# /b <br /> COMMENTS1 8l <br /> PE SC Received ChecI* Amount Date Permit/ Invoice# Well ID* <br /> Codes Into Cash Remitted Service Request 0- <br /> 143-73 <br /> EHD 43-08 N-3502-7/ WELL DESTRUCTION PERMIT <br /> 11/23/21 <br />