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EMAILE �MR�.�a a4sg Vj�tQ�N <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 V CITY/ZIP rG r I \ Z �: <br /> CROSS STREET. APN PARCEL$127E LAND USE APPLICATION# o <br /> OWNER ( PHONE <br /> 1 �i}��� -'7 r V <br /> OWNER ADDRESS 1 r CITY/STATE/ZIP'l• cIr 1 �Jf�J 'gQ5GI <br /> CONTRACTOR M S 11 Drill V PHONE -201 � :;2-2 I1ZV <br /> CONTRACTOR ADDRESS IIS I CITY/STATEIZIP M od( l Gtt j ` 93f32 <br /> W C-57 WELL DRILLING LICENSE NUMBER 1I V U2 7^ EXPIRATION DATE O�- �V. Z! T <br /> PERFORATION CONTRACTOR PHONE n <br /> PERFORATION CONTRACTOR ADDRESS CITY/STATEIZIP MAR 7 <br /> ❑ C-57 Well Drilling License Number ExpiraMgr� Z� <br /> ❑ Bureau of Alcohol,Tobacco and Firearms-Users of High Explosives License Number Expiri �' Q(J� <br /> ❑ CHP Hazardous Material Transportation for Explosives License Number Expirat or�/D-U, �N �I N y <br /> ❑ San Joaquin County Sheriff-Coroner Explosives Application and Permit License Number Expiration Date /EN <br /> ❑California Occupational Safety Health-Blaster License Number Expiration Date <br /> REASON FOR DESTRUCTION )AI 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 ❑ 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 ConclurAor Casing ft bgs Diameter of Conductor Casing inches <br /> Well Casing Diameter_\`)_ -_ inches Total Depth ft Depth to Water11�0 _ft Depth of Casing ft bgs <br /> DESTRUCTION SPECIFICATION <br /> Sealing Material from _-- ft bgs to-IL 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 /> ❑ Mills Knife _ _Number of cuts every ft and/or <br /> ❑ Explosives ❑ Detonating cord ❑ with projectiles everyft ❑ without projectile <br /> ❑ Detonating cord and boosters ❑ with projectiles every ft 0 without projectile <br /> ❑ Other <br /> Sealing Material Neat Cement(94 Ib bag/5-6 gal water) Sand Cement sack mix/7 gal water Bentonite <br /> Pelle <br /> Bentonite(20° solids) Manufacturer Spec%solids % Name Specs on File Specs Submitted <br /> Placement Method Pumped Free Fall Other <br /> Seal Completion Complete 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 ' /d-12 <br /> � � Area Y 9q <br /> Application Accepted By Date v <br /> Destruction Inspection By � I- Date LILI�I l Z,9 Employee ID# 12 L <br /> COMMENTS ` D IO�4 Q4 � y kA..i e s cd <br /> PE I SC Received Check#/ Amount Date Permitl Invoice# Well ID# <br /> Codes Info Cash Remitted Service Request# <br /> v3 8 0(00 -AZ lZU4 W0045317 <br /> � . � 175�3131aSb <br />