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WELL DESTRUCTION PERMIT <br /> PUBLIC WATER SYSTEM ❑Yes ❑No <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1866 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 /> U. <br /> JOB ADDRESS CITYIZIP CLKM �- <br /> CROSS STRFET APN PARCEL SUE <br /> G� LAND USE APPLICATION# � <br /> OWNER A PHONE AM �41 v,Io <br /> til <br /> OWNER ADDRESS CITYISTATE/ZIP�{ b� (A 191,I r <br /> CONTRACTOR0AWM Nv . A� <br /> PHONE ` /��y '] <br /> CONTRACTOR ADDRESS I CrTY/STATE/ZIP 1V\O CA - tet,17� / <br /> QIP Cti57 WELL DRILLING LICENSE NUMBER V V EXPIRATION DATE <br /> PERFORATION CONTRACTOR PHONE <br /> PERFORATION CONTRACTOR ADDRESS CITYISTATE/Z1P <br /> ❑ C-57 Well Drilling License 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 /> ❑ Califomia Occupational Safety Health-Blaster License Number Expiration Date <br /> REASON FOR DESTRUCTION Dry ❑ Replacement Well ❑ Caved In ❑ Pit Well ❑ Inactive ❑ Test Hole <br /> Detected/Suspected Well Wat r ontaminant(s) <br /> Adjacent property with contamination(Address) <br /> Known Soil/Water contaminants at adjacent property <br /> EXISTING WELL CONSTRUCTION DETAILS ❑ Open Bottom Gravel Pack ❑ Uncased ❑ Other <br /> Well Log copy attached ❑ Yes ❑ No Grout Seal ❑ No ❑ Yes R below ground surface(bgs) Hole Diameter _ _ inches <br /> Well Conductor Casing ❑ Yes ❑ No Depth of Condu 9 r Casing ft b s Diameter of Conductor Casing inches <br /> Well Casing DiameterII inches Total Depth It Depth to Water �ft Depth of Casing it bgs <br /> DESTRUCTION SPECIFICATION <br /> Sealing Material from _V_It bgs to 110 It bgs Filler Material from It bgs to ft bgs <br /> Well casing to be perforated by one of the following methods: from It bgs to fts AYM N <br /> ❑ Mills Knife Number of cuts every ft and/or_ EC C•II / <br /> ❑ Explosives ❑ Detonating cord ❑ with projectiles everyft ❑ without projectile C AD <br /> ❑ Detonating cord and boosters ❑ with projectiles everyft ❑ without projectile ILEB❑ Other C 8 OZ� <br /> Pelletes "joaling Material Neat Cement(94 lb bag/5-6 gal water) Sand Cement sack mixf7 gal water 8"38e <br /> Bentonite(20%aolids)� Manufacturer Spec%solids % Name Specs on File y — 's'ftN UN7' <br /> Placement Method Pumped Ij Free Fall / Other DEPART AL <br /> Seal Completion Oomplete with Mushroom Cap ft bgs = Complete to Existing Surface Pad ENT <br /> MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS, CALL(209)953-7697 FOR INSPECTIONS <br /> DEPARTMENT USE OhlY 1 <br /> --�� •� <br /> Application Accepted By r __ Date Area r <br /> Destruction Inspection B `y S\ Date\7----,, Employee ID# <br /> COMMENTS T 70 al, t7 <br /> PE SC Received Check#I Amount Permit/ <br /> Codes Info B Cash Remitted Date Service R uest# Invoice# Well ID# <br /> � 9 WELL DESTRUCTION PERMIT <br /> EHD/21 ( l3��/ 7e�8 <br /> 17/23/21 �-CJ <br />