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WELL DESTRUCTION PERMIT <br /> PUBLIC WATER SYSTEM ❑Yes ❑No <br /> SAN JoActuM COUNTY E►mRoNMENTAL HEALTH DEPARTMENT 1868 East Hazelton Avenue-STOCKTON CA 95205 - (209)4683420 <br /> NON-REFUNDABLE PERMIT AL 2 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> ICU <br /> v, <br /> Joe ADORES$ CrnlZP M <br /> C=ER <br /> AWO 619U2 <br /> STREET APN PARCEL SIZE 'L AND Usr:APPtjcAATION# <br /> PHDNE ? rr n !�nl1r�rr!1 <br /> OwNat ADORs r, C►rYISTATE01P �SCjald N 497; /i{J <br /> CONTRACTOR V ="Y/STATEMP <br /> CONTRACTOR ADDR£Sg �J <br /> i� C-5i7 WELL DRILLING LK ENSE NUMBER I��.� �L!/ EXPIRATION DATE <br /> IPERFORA` TION CONTRACTOR PHONE <br /> PERFORATION CONTRACTOR ADDREss Cn'YISTATErLP <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 Pemttt License Number Expiration Date <br /> ❑ Caifornw Occupationalty Heatlh-Blaster Dense Number Expiration Date <br /> REASON FOR DEsTRVCTION ❑ Replacement Wel ❑ Caved In ❑ Pit Well ❑ Inactive ❑ Test Hole <br /> Detected/Suspected Well W CorrtamM►ant(s) <br /> Adjacent property with contamination(Address) <br /> Known SoilfWater contaminants at adjacent property- <br /> Ex*TING WELL CONSTRUCTIWN DETAILS ❑ Open Bottom Gravel Pads ❑ Uncased ❑ Other <br /> Well Log copy attached ❑ Yes Q No Grout Seal ❑ No Yes It below ground surface(bgs) Hole DiameterInches <br /> Well Conductor Casing 11 Yes ❑ No Depth of C COL Casing ft Diameter of Conductor Casing inches <br /> Wel Casing Diameter inches Total Depth ._ft Depth to Water �R Depth of Casing It bgs <br /> DESTRUCTION SPECIFICATION <br /> Sealing Materlal from .it bgs to R bgs Filler Matedal_ from R bgs to ft bgs <br /> Well casing to be perforated by one of the following me0yoft: from R bgs to ft bgs <br /> ❑ Mills Knife Number of alts every ft and/or _ <br /> ❑ Explosives ❑ Detonating cord ❑ with projectiles every R ❑ without projectile <br /> ❑ Detonating cord and boosters ❑ with projectiles every_ft ❑ without projectile <br /> ❑ Other <br /> PelISSpaling Material I Neat Cement(94 Ib baglr6 gal watei)17 Sand Cement sack mW7 gal water 11 Bentonite <br /> Bentonite( ids) a Manufacturer Spec%solids-% Name Specs on File ❑ Specs Submitted <br /> PlacementM Pumped I1 FreeFall�j,I Older <br /> Seal Completion plate with Mushroom Cap ; ft bgs ri Complete to Edsdng Surface Pad <br /> MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS,CALL(209)953-7697 FOR INSPECTIONS <br /> DEPARTMENT USE ONLY 27 ZZ Area <br /> Application Accepted By Date Ol <br /> Destruction Inspection By Date `. .�� ��� Employee ID# e <br /> COMMENTS <br /> Ty <br /> ReceivedPE SIC <br /> Codes Info YCCash AmountIttd Date Service Request a« Invoices wap Nr <br /> EHD 43-08 .• I n I / Ip( I WELL DES 1 KUCTION PERMrT <br /> 11/23121 <br />