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WELL DESTRUCTION PERMIT PUBLIC WATER SYSTEM ❑Yes ❑No SAN JoAounl COUNTY ENVROIIMENTAL 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 Jos ADDRESS CITYfZ� �/ Q S�✓� CROs APN Z — PARCEL S LAND USE APPL)cATioN 8 OwNErt IV PHONE200 . /� QW t ADDRESS111-71 E.y Y- CrrY/STATEMPVI N CONTRACTORMaZft� f IJltffQ PH )ONE Cf72' 1q2,&. CONTRACTMADDRESS AA CrrY/STATdItP O C-57 WELL DRa.uwc LKNSE NumBER J V U ��Z-- EXPIRATION DATE PERFORATION CONTRACTOR A��f N L PHONE [��Z61 PERFORATION CONTRACTOR ADDRESS!_( _ CUY1STAT6ZIP t` (n} XG-57 Well Drilling License Number 7i Expiration Date�v^h ❑ 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 ❑ Caltfomia Occupational Safety Health-Blaster License Number Expiration Date REAUM FOR DEOTRucrgN ❑ Dry ❑ Replacement Well Caved I n ❑ Pit Weil ❑ inac1ive ❑ Test foie Detecteci/Suspected Well Water ConbrnkwK(s) Adjacent property with contamination(Address) Known SoiVWater corltanrinants at adjacent property -- ExiSTWG WELL.CONSTRUCTION DIFTMA ❑ Open Bottom Tavel Pack ❑ Uncased ❑ Other Wel Log copy attached ❑ Yes ❑ No Grout Seal ❑ No ❑ Yes _ft below ground surface(bgs) Hole Diameter---__inches Well Conductor Casing❑ Yes ❑ No Depth of Casing ft Diameter of Conductor Casing inches Well Casing DlameLer!�r inches ToW Depth f ft Depth to Water _,R Depth of Casing--- fl logs DESTRUCTION SPECIFICATION N Sealing Material from 3fIt bgs to�ft bgs Filler Material_ _. from _ft bgs toes, / Well casing to be 2d2 ed by one from ft bgs to It bgs D Mills Knife I _Number of cuts every ft and/or — — O V 17 7 Explosives❑ Detonating cord ❑ with projectiles every11- ft without projectile S / z 21 13Detonating cord aridboosters E3 with projectiles every_ ft ❑ without projectile AN JOq ElDther - - NEENVIRONMEC� NTy PalttVting Material LI Neat Cement(941b bag/5-6 gat water)i Sand Cement sack mix(7 gal water ElBeMOFii�p�RTT L Bentonite(20Xds) Manufacturer Spec%solids % Name + Specs on File n Specs submitted M NT Placamord M Uod Pumped ❑ Free Fall Other Seal Completion --1 Complete with Mushroom Cap ft bgs U Complete to Existing Surface Pad MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS,CALL(209)953-7697 FOR INSPECTIONS EPARTMENT USE ONLY f 9 Application Accepted By Date DesVucbm Inspechon B f Date 111IT123, Employee ID# COMMENTS PE = ttseelved Ctn eatdH Ahnwunt Dam PerrrltU Invoice ale Well IDI' Codas kdo Citi Remitted SmAce f 3165' V1,5�- 32S 11 I-r al , 2 WELL DESTRUCTION PERMIT EHD 11fY.iir11 i /'v'ct ' l s3 6'1 J,5� v