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WELL DESTRUCTION PERMIT <br /> PUBLIC WATER SYSTEM [:]Yes ❑No <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 East Hazelton Avenue-STOCKTON CA 95205 - (209)4683420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> ///��3� I INV TEC A 9s 3 3 �JOB ADDRESS <br /> CROSS STREET L-EFTA _5*F APN /?r,;Z 7003 PARCEL SIZE o LAND USE APPLICATION# b <br /> ^r b <br /> OWNER oi,'N c_ALI Fo12NlA a3 LLC PHONE Z11, '"3�S/32-q <br /> OWNERADDRES/S, H S _,/`p/'/C Pony AK , SiE Ion CRY/STATE/ZIP /.QSC!/ILLG �� 9566/ <br /> ry <br /> CONTRACTOR E0,1114A W EL-L .Se_R✓l'CE S /,V& PHONE 2A . 38-3— 3L.,41. <br /> CONTRACTOR ADDRESS Po &X Z9 us-s - CRY/STATE/ZIP -SAC-7-0'I CA clI9Z� <br /> 9;?--C-57 WELL DRILLING LICENSE NUMBER IOq EXPIRATION DATE 9 I.3t. IgLf <br /> PERFORATION CONTRACTORA'ILMJ,_1_ NS/ Gy�L n--si:X 11 PHONE ft -- 76/ — 5ZZ-4 <br /> 1 <br /> PERFORATION CONTRACTOR ADDRESS t6 317 UALstf/]iAr( hl' 5tf S 4by 1p CITY/STATE/ZIP 664X&_& qSL-1aA ', 04 /371Z <br /> ❑ C-57 Well Drilling License Number Expiration Date <br /> 0 Bureau of Alcohol,Tobacco and Firearms-Users of High Explosives License Number OPV FlL C Expiration Date <br /> CHP Hazardous Material Transportation for Explosives License Number Expiration Date <br /> 4- San Joaquin County Sheriff-Coroner Explosives Application and Permit License Number Expiration Date <br /> IT 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 Well Water Contaminant(s) <br /> Adjacent property with contamination(Address) <br /> Known Soil/Water contaminants at adjacent property <br /> EXISTING WELL CONSTRUCTION DETAILS ❑ Open Bottom � Gravel Pack ❑ Uncased EI Other <br /> Well Log copy attached 11 Yes ❑ No Grout Seal ❑ No 10/Yes otft below ground surface(bgs) Hole Diameter /G._inches <br /> Well Conductor Casing EY Yes ❑ No Depth of Conductor Casing U ie— ft bgS Diameter of Conductor Casing 3_inches <br /> Well Casing Diameter 16 inches Total Depth ' 7'�1 ft Depth to Watery, ft Depth of Casing,� 7S ft bgs <br /> DESTRUCTION SPECIFICATION <br /> Sealing Material from 2_7f ft bgs to 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 /> ❑ Mills Knife Number of cuts every ft and/or <br /> Explosives ❑ Detonating cord ❑ with projectiles every ft ❑ without projectile <br /> Ilk Detonating cord and boosters 0 with projectiles every iI) ft ❑ without projectile <br /> ❑ Other <br /> Pel eps Img Material [I Neat Cement(94 lb bag/5-6 gal water)L�Sand Cement /b• 3 sack mix/7 gal water = Bentonite <br /> I Bentonite(20%solids) i i Manufacturer Spec%solids % Name i Specs on File Specs Submitted <br /> Placement Method ❑ Pumped _J Free Fall :1 Other <br /> Seal Completion fY Complete with Mushroom Cap 5 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 Z 2 1 Z`� Area v 5 i"1�``��k / L <br /> Destruction Inspection By Date q Employee I <br /> COMMENTS d 1 L+ �� `�� ��� L o� <br /> J <br /> F a <br /> s PE SC ReceivedChe Amount Permit/ <br /> 1 Codes Info B ash Remitted Date Service Request# Invoice# ell ID# <br /> 13 ( 7 3Z <br /> I, <br /> EHD 43-08 WELL DESTRUCTION PERMIT <br /> 11/23/21 <br />