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fn WELL DESTRUCTION PERMIT 5'o�� s l I �'�V lC /�/�° l�✓`" " l (o (� �j 1�,r j_rt k a vv 4 u e- ? A P W 2-2 PUBLIC WATER SYSTEM C ties ❑Nc. 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 L^ tV N CRY(ZIP �J �- .✓� J CROSS STREET1holkiAPN PARCEL SIZE2.•Z11^�AND USE APPLICATION# _ OWNERA16 '�{1 PHONE ' V-1 1 �/ Feb N OWNER ADDRESS /1 Nh,/� CITYISTATTEIZ(IIP (� �j CONTRACTOR I I V U PHONE q. '/a CONTRACTOR ADDRESS I� CITYISTATE/ZIP��' C-57 WELL DRILLING LICENSE NUMBER Ex PIRATION DATE L1 242,V1 PERFORATION CONTRACTOR PHONE "T PERFORATION CONTRACTOR ADDRESS CfTYISTATEIZIP ❑ G-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 Dat ❑ San Joaquin County Sheriff-Coroner Explosives Application and Permit License Number Expiration D / ❑ California Occupational Safety Health-Blaster License Number Expiration Dat REASON FOR DESTRUCTION Dry ❑ Replacement Well ❑ Caved In ❑ Pit Well ❑ Inactive OJ grat,Hole Detected/Suspected Well Wat r Contaminant(s) Adjacent property with contamination(Address) ____ ANs •�Z��' Known Soil/Water contaminants at adjacent property_ T ExisnNG WELL CONSTRUCTION DETAILS ❑ Open Bottrnn Gravvi Pack ❑ Uncased ❑ Other RT'ZN T Well Log cony attached 11 Yes ❑ No Grout Seal ❑ No ❑ Yes fl below ground surface(bgs) Hole Diameter orches Well Conductor Casing ❑ Ves ❑ No Depth of Condor Casing It/b�s/� Diameter of Conductor Casing Inches Well Casing Diameter�T inches Total Depth I J i f Depth to Water V fT ft Depth of Casing ft logs DESTRUCTION SPECIFICATION `1 -W Sealing Material from G__ft bgs to V ft bgs Filler Material_ _ from ft logs to Well casing to be perforated by one of the following methods: from ft bgs to ft bgS ❑ Mills Knife _-_ Number of cuts every ft and/or Explosives ❑ Detonating cord ❑ with projectiles every ft ❑ without projectile ❑ Detonating cord and boosters ❑ with projectiles every ft ❑ without projectile 7 Other Sealing Material Neat Cement(94 Ib bag/5-6 gal water) Sand Cement sack mix/7 gal waterJt Bentonite D Pellets v Bentonite(20%solids) Manufacturer Spec%solids % Name _ _ Specs on File 1 Specs Su ittedF Placement Method Pumped Free Fall 0 Other Seal Completion Complete with Mushroom Cap ft bgs Complete to Existing Surface Pad 0 MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS, CALL(209)953-7697 FOR INSPECTIONS DEPARTMENT USE ONLY r Application Accepted By Date Area LSL `` Destruction Inspection ByII-- /I Date 10 (IR 2- Employee ID# COMMENTS G Ky�1�t/lT Lt�l u�v� I '� R V tiLV�� ✓L LAk-o1i1 4 '41eli PE Sc Received Check#/ T Amount Date Permit/ Invoice III Well IDO Codes Info Bv Cash RemittedService Request# LOS. EHD 43-08 � // G� WELL DESTRUCTION PERI /(J l 1 tl23r2 t