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t EMAILED 1), qqMO 4 N FrM It PUBLIC WATER SYSTEM El Yes ❑No SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 East Hazelton Avenue-STOCKTON CA 95205 - (209)468-3420 NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS ( ( EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS / v� CITY(ZIP f Vii ION 1, ��/��V "I ��1 n j� M CROSS STREET �X APN �'lrJ Oq0 110 PARCEL SIZEI 2- LAND GUSE ,j-APPLICATION# ��p OWNER ` Z V PHONE J OWNER ADDRESS (�1f\V,(�/ I '`t�e'i ' " 1� (/ CITYISTATE/ZIP flSCil CONTRACTOR F�A� �(V(�I 1� 1Vty-'y/,� I��N' I N" PHONE � 1� J CONTRACTOR ADDRESS � `►/�I CITYISTATFJZIP C-57 WELL DRILLING LICENSE NUMBER 2— EXPIRATION DATE PERFORATION CONTRACTOR PHONE PERFORATION CONTRACTOR ADDRESS CITY/STATE/ZIP ❑ C-57 Well Drilling License Number Expiration Date ❑ Bureau of Alcohol,Tobacco and Firearms-Users of High Explosives License Number Expiration Date ❑ CHP Hazardous Material Transportation for Explosives License Number Expiration Date ❑ San Joaquin County Sheriff-Coroner Explosives Application and Permit License Number Expiration Date ❑ California Occupational Safety Health-Blaster License Number Expiration Date REASON FOR DESTRUCTION Dry ❑ Replacement Well ❑ Caved In ❑ Pit Well ❑ Inactive ❑ Test Hole Detected!Suspected Well Water Contaminant(s) Adjacent property With contamination(Address) Known Soil/Water contaminants at adjacent property EXISTING WELL CONSTRUCTION DETAILS ❑ Open Bottom Gravel Pack ❑ Uncased ❑ Other Well Log copy attached ❑ Yes t3"INo Grout Seal ❑ No ❑ Yes _ ft below ground surface(bgs) Hole Diameter inches Woll Conductor Casing ❑ Yes ❑ No Depth of Conductor Casing fts Diameter of Conductor Casing_ inches Well Casing Diameter_ inches Total Depth V ' ' ft Depth to Water 0, Oft Depth of Casing ft bgs DESTRUCTION SPECIFICATION ��^^ YM Sealing Material from L ft bgs to `6c� ft bus Filler Material from _ft bgs to R� `c$, N� Well casing to be perforated by one of the following methods: from ft bgs to ft bgs I CD ❑ Mills Knife __. _ Number of cuts every- ft and/or NO O ❑ Explosives ❑ Detonating cord ❑ with projectiles every_ ft ❑ without projectile J ❑ Detonating cord and boosters ❑ with projectiles every_ ft ❑ without projectile SA/V J Cl Other H EN R QUA/CO Pellets ling Material Neat Cement(94 Ib bag/5-6 gal water) Sand Cement sack m&7 gal water r�tprt{ NgFN7NJ-y. Bentonite(20%solids) Manufacturer Spec%solids % Name Specs on File Specs S�ubb/mJittetl M /�T Place ent Method X Pumped Fr Fall Other Seal Completion Complete with Mushroom Cap fl bgs Complete to Existing Surface Pad MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS, CALL(209)953-7697 FOR INSPECTIONS D E P A R T M E NT US E O N LY 'L Application Accepted By Date l Area U Destruction Inspection By Date 1 Employee ID# COMMENTS PE SC Received Check#! Amount Date Permit Invoice# Well IDX Codes n B Cash Remitted Service Request# / `mac- t 23 T t 7 00 It 1 /T2