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►�5�1'UG�i D� j�-�r��{�. PUBLIC WATER SYSTEM ❑Y(y: ❑No SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 East Hazelton Avenue-STOCKTON CA 95205 - (209)468-3420 NON-REFUNDABLE PERMIT [ /� CALL(20079) 95^3-,{7697 FOR INSPECTIONS ( (`EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS 1 n5% J F (j�t lu fl PA I I V 1 ��. ►"y" 11 __CITY(ZIP ES0,110N,110N C A 9 5�z G t�\�to,- � APN-2 1— (30— 0410 PARCEL SIZE�LAND USE APPLICATION# C' CROSS STREET, , I'� /j O OWNER ++ PHONE 012 q 23 `tet� /� OWNER ADDRESS91� ( ^� ( 1f CITYISTATEIZIP C/lt ton ccl q',5�Zll CONTRACTORMU //��J OI I I r7 PHONE '� Z G�j CONTRACTOR ADDRESS "1RCR� CITY/STATE/ZIP J7hCt- C-57 WELL DRILLING LICENSE NUMBER �� EXPIRATION DATE PERFORATION CONTRACTOR PHONF PERFORATION CONTRACTOR ADDRESS CITYISTATEIZIP ❑ C-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 Date ❑ San Joaquin County Sheriff-Coroner Explosives Application and Permit License Number Expiration Date ❑ Califomia Occupational Safety Health-Blaster License Number Expiration Date REASON FOR DESTRUCTION Dry ❑ Replacement Well Caved In ❑ Pit Well ❑ Inactive ❑ Test Hole Detected/Suspected Well Wa r Contaminant(s)_- Adjacent property with contamination(Address) Known Sot(/Water contaminants at adjacent property E.xISTING WELL CONSTRUCTION DETAILS ❑ Open Bottom Gravel Pack ❑ tlncaSed ❑ oiiie, Well Log copy attached ❑ Yes D No Grout Seal ❑ No ❑ Yes ft below ground surface(bgs) Hole Diameter _inches Well Conductor Casing ❑ Yes ❑ Nu Depth of Conductor Casing ft.b Diameter of Conductor Casing_ _inches Well Casing Diameter a4 inches Total Depth w ft Depth to Water 7 ft Depth of Casing_ _ ft bgs DESTRUCTION SPECIFICATION hie Sealing Material ircm ft hgs;n �G ft/xis Filler Material_ _ from __ ft bgs to Wel casing to be perforated by one of the following methods: from ft bgs to Mills Knife _Number of ruts every_r�ft and/or_. Jf A' I Explosives ❑ Detonating cord ❑ with projectiles every ft ❑ without proje�I a /Y ❑ Detonating cord and boosters ❑ with projectiles every ft ❑ without projec6(aN'lO ��?O ❑ other_ Sealing Material Neat Cement(94 lb beg/5-6 get water) Sand Cement sack mir17 gal water COO Pellets. Fp Nr Nj Bentonite(20%solids) Manufacturer Spec%solids % Name Specs on File Specs P acement Method Pumped Free Fall 7 Other tiT Seal Completion Complete with Mushroom Cap _. _ ft bgs Complete to Existing Surface Pad MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS, CALL(209)953-7697 FOR INSPECTIONS DEPARTMENT USE O N Y Apples Accred By Date I I a� Area 0!q1 lit Destruction Inspection By Date S 2-q Employee ID# COMMENTS :[Cl CGvt�2 T l N�A.L CL k W /J1-, PE SC Received ChecI10 Amount Date Permild Invoice# Well ID# Codes Info B Cash Remitted Service RequM# , Z i �2 zy 2-22-