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i <br /> S <br /> PUBLIC WATER SYSTEM ❑Yes ❑No <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 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 /> JOB ADDRESS l00!1 110 <br /> (� CITY/Zip <br /> CROSS STREET ) APN22� ZZO-- O PARCEL SIZE�aLAND USE APPLICATION# y <br /> c <br /> (� rG T <br /> OWNER hN G PHONE -I 40+ +n�!%0 'v <br /> OWNER ADDRESS P-0. ( O (�' CITY/STATE/ZIP ud4V' G cu �(�3 y <br /> CONTRACTORlv" a q }O�� N V PHONE �O(� Il L- 2-4 r <br /> CONTRACTOR ADDRESS I�-1 t 1 IPV�J ''nn CITYISTATE/ZIP IVL V I f Gr� rq`5-3'7 7 <br /> C-57 WELL DRILLING UCENSE NUMBER O V M 22— EXPIRATION DATE O9 ZIIZ✓J <br /> PERFORATION CONTRACTOR PHONE <br /> PERFORATION CONTRACTOR ADDRESS CITY/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 /> REASON FOR DESTRUCTION Dry ❑ Replacement Well ❑ Caved In ❑ Pit Well ❑ Inactive ❑ Test Hole <br /> Detected/Suspected r CWell Wa ontaminant(s) <br /> Adjacent property with contamination(Address) <br /> Known Soi'Water contaminants at adjacent property <br /> ExIST1NG WELL CONSTRUCTION DETAILS ❑ Open Bottom Gravel Pack ❑ Uncased ❑ Other <br /> Well Log copy attached ❑ Yes ❑ No Grout Seal ❑ No ❑ Yes ft below ground surface(bgs) Hole Diameter. inches <br /> Well Conductor Casing❑ Yes ❑ No Depth of Cond o1r Casing It Diameter of Conductor Casing inches <br /> Well Casing Diameter rt inches Total Depth ft Depth to Water _ ft Depth of Casing _ _ _ ft bgs <br /> DESTRUCTION SPECIFICATION PAYMENT <br /> I <br /> Sealing Material from __�ft bgs to _VOIt bgs Filler Material _ _from _ ft bgs to RECEIWeDi <br /> Well casing to be perforated by one of the following methods: from ft bgs to ft <br /> ft bgs 202 <br /> ❑ Mills Knife _..______ Number of cuts every._._ _ft and/or _ 1 <br /> ❑ Explosives ❑ Detonating cord ❑ with projectiles ever)(__ It ❑ without projectile <br /> 5AN QDINCOUNly <br /> ❑ Detonating cord and boosters ❑ withprojectiles eve ry ft ❑ without projectile ENVIRNMENTM1L <br /> ❑ Other HEALTH DEPARTMENT <br /> PellSealing Material Neat Cement(94/b beg/5-8 gal water) Sand Cement _ sack mix17 gal water Bentonite <br /> Bentonite(20%T.mplete <br /> ds) Manufacturer Spec°1 solids % Name Specs on File Specs Submitted <br /> PI ement Method Pumped Free Fall 1 Other <br /> Seal Completion with Mushroom Cap ft bgs Complete to Existing Surface Pad <br /> MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS, CALL(209)953-7697 FOR INSPECTIONS <br /> DEPARTMENT USE ONL <br /> Application Accepted By Date 10 O Area <br /> Destruction Inspection By Date2- Employee ID# <br /> COMMENTS L i i,.�• ,1 a < .) "+1 ZC I. �6�) <br /> ! PE I SC Received Check#/ Amount Date Permit/ Invoice# Well IDS <br /> Codes Info Cas Remitted Service Request# <br /> I <br />