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EMAILED ��vGt1�N I���n�.1-t-• <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 CnAf L 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS 1`l CITY/ZIP <br /> CROSS STREET APN PARCEL SVARLAND USE APPLICATION# C <br /> c <br /> X <br /> F. <br /> OWNER` PHONE /�/'� /p <br /> OWNER ADDRESS ►/� <br /> CITY/STATE/ZIP f I i a 0 l r/a <br /> CONTRACTOR ar PHONE <br /> CONTRACTOR ADDRESS CITY/STATE/ZIP r _ <br /> C-57 WELL DRILLING LICENSE NUMBER U U U I- EXPIRATION DATE <br /> PERFORATION CONTRACTOR PHONE <br /> PERFORATION CONTRACTOR ADDRESS CITYISTATE/ZIP <br /> ❑ C-57 Well Drilling License Number Expiration Date <br /> ❑ Bureau of Alcohol,Tobacco and Firearms-Users of High Explosives License Number Expiration Dat <br /> ❑ CHP Hazardous Material Transportation for Explosives License Number Expiration DaP <br /> ❑ San Joaquin County Sheriff-Coroner Explosives Application and Permit License Number Expiration <br /> ❑ California Occupational Safety Health-Blaster License Number Expiration Dale <br /> REASON FOR DESTRUCTION Dry ❑ Replacement Well ❑ Caved In ❑ Pit Well ❑ Inactive E14#t bb <br /> Detected/Suspected Well Water Contaminant(s) SA A, <br /> Adjacent property with contamination(Address) <br /> Known Soil/Water contaminants at adjacent property_ __ AST"�IIjFr�lT /V�l Sri <br /> EXISTING WELL CONSTRUCTION DETAILS ❑ Open BottomGravel Pack ❑ Uncased ❑ Other VT <br /> Well Log copy attached ❑ Yes ❑ No Grout Seal ❑ No es ft below ground surface(bgs) Hole Diameter _ inches <br /> Well Conductor Casing ❑ Yes ❑ No Depth of Conductor Casing ft t Diameter of Conductor Casing_ inches <br /> Well Casing Diameter_4— inches Total Depth_ft Depth to Water _ft Depth of Casing ft bgs <br /> DESTRUCTION SPECIFICATION -10 <br /> Sealing Material from ft bgs to _ft bgs Filler Material _ from _. __._ft bgs to _ft bgs <br /> Well casing to be perforated by one of the following methods: from ft bgs to ft bgs <br /> ❑ MillsKnife __ Number of cuts every ft and/or--___. <br /> ❑ Explosives ❑ Detonating cord ❑ with projectiles every___—ft ❑ Without projectile <br /> ❑ Detonating cord and boosters ❑ with projectiles every_ ft ❑ without projectile <br /> ❑ Other— <br /> Sealing Material Neat Cement(94/b begl5-6 gal wafer) Sand Cement sack mix/7 gal water Bentonite <br /> Pellets <br /> lc� <br /> Bentonite(20°0 olids) Manufacturer Spec%solids % Name Specs on File Specs Submitted <br /> ment Method Pumped _J Fr FII Other <br /> Seal Completion Complete with Mushroom Cap It bgs Complete to Existing Surface Pad Li` <br /> MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS, CALL(209)953-7697 FOR INSPECTIONS <br /> DEPARTMENT USE ONLY , y /99 <br /> Application Accepted By Date / /g,/2,L/ Area <br /> Destruction Inspection By 1 Date — �— 7-t/L / Employee ID# L <br /> COMMENTS? � to A,�- 774,1- <br /> PE <br /> 74,EPE SC Received Check#1 Amount Date Permit/ Invoice# Well ID# <br /> Codes Info BV Cash Remitted Service Request# <br /> 3b 0& �;�— /b 2 ml�ro��z� I��rom�5►az <br /> �} 777 ��G� <br />