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WELL DESTRUCTION PERMIT <br /> PUBLIC WATER SYSTEM ❑Yes ❑No <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 7668 East Hazefton 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 ADDRESS CtTYIZIP G M <br /> a <br /> CROSS S VA APN PARCEL S ' LAND USEATION o <br /> TLIC p <br /> Y PHONE <br /> SER tin0AW CITYISTATEIZIP <br /> CONTRACTOR PHONE <br /> TOR AnDF&M CITYISTATEIZIP <br /> C-57WELL DRILLING LICENSE NUMBER ExPATN DATE <br /> TION CONTRACTOR PHONE <br /> PERFORATION CONTRACTOR ADDRESS CrrY/STATE/ZIP <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 /> ❑ California Occupational Safety Health-Blaster License Number Expiration Date <br /> R FOR DESTRUCTION- Dry ❑ Replacement Well ❑ Caved In [IPit Well EIInactive [ITest Hole <br /> Detected/Suspected Well W ontaminant(s) <br /> Adjacent property with contamination(Address) <br /> Known SoiVWater contaminants at adjacent property_ <br /> EXSTING WELL CONSTRUCTION DETALS ❑ Open Bottom Gravel Pads ❑ Uncased ❑ Other--- <br /> Wei <br /> ther _Wei Log copy attached ❑ Yes ❑ No Grout Seal ❑ No ❑ Yes ft below ground surface(bgs) HoleDlameter inches <br /> Wei Conductor Casing❑ Yes ❑ No Depth of Con�ugtp�Casing Diameter of of Conductor Casing inches <br /> Wei Casing Dianwr ar. inches Total Depfh_�/�}�/� ft Depth to W-tt-r Depth of Casing ft bgs <br /> DESTRUCT"SPECFI AT1C <br /> Sealing Material from ft bgs to _ft bgs Filler Material from ft bgs to _ft logs <br /> Well casing to be oerhxra d by one of the followlrw methods: from ft bgs to ft bgs <br /> ❑ Mills Knife Number of cuts every ft and/or_ _ <br /> ❑ Explosh ms❑ Detonating cord ❑ with projectiles everyIt ❑ waxKA projectile <br /> ❑ Detonating cord and boosters ❑ with projectiles everyft ❑ without projectile <br /> ❑ Other <br /> Sealing <br /> a ing Material I i Neat Cement(94 Ib ba95-6 gal water) ' Sand Cement sack M&9 gal water ❑ Bentonite <br /> Bentonite(20%solids) ' Manufacturer Spec%solids % Name Specs on File 11 Specs Submitted <br /> PI t Method G Pumped Free Fall tOther <br /> Seal Completion F1 Complete with Mushroom Cap I ft bW C Complete to Existing Surface Pad <br /> MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS, CALL(209)953-7697 FOR INSPECTIONS <br /> Z DEPARTMENT USE O/N7 Y <br /> Application Accepted By. <br /> L Date "l�r� d k� Area <br /> Destruction Inspection By Date Employee ID9 <br /> COMMENTS r~t.��aaE� T <br /> 1'/'1 i Irl C ry 1 <br /> RECEIVED <br /> -SEP 2 1 2022 <br /> 60 X)AGUIN TY <br /> ENV <br /> PE SC Received Cheeldi Amount permit/ Invoice# IRof AL <br /> Codas Info Cast, Remitted Date Service nest 11 H LTH D N <br /> EHO 43.E GO/1 \ ,J OD -1 WELL DESTRUCTION FCRMIT <br /> 11/23121 l <br />