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E ' <br /> EMAILED <br /> �ie11 <br /> De sk w Jk ovi <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 I —7,41 1. IMt V(V� 10 CITY21P �n I,,►,�I ��"�j��-, <br /> c2;�RIPONC( <br /> _Z.SPARCEL SIZE LAND USE APPLICATION W#CROSSSTREET APN <br /> OWNER 'W� FlUVA PHONE 0 0• 01122- <br /> OWNER ADDRES <br /> ZLOWNERADDRESS T7J—I Ct` � CITY/STATE/ZIP CA 11 0 <br /> CONTRACTOR MAI�tlh� I +IrlI PHONE 201 c;Z2-- 02 / <br /> CONTRACTOR ADDRESS 01 ft' S CITY/STATE/ZIP / (5 r <br /> — <br /> 'PA1 C7-7 <br /> y C-57 WELL DRILLING LICENSE NUMBER Z EXPIRATION DATE <br /> PERFORATION CONTRACTOR PHONE <br /> PERFORATION CONTRACTOR ADDRESS CITY/STATE/ZIP <br /> ❑ C-57 Well Drilling License Number Expiration Date <br /> ❑ Bureau of Alcohol,Tobacco and Firearms-Users of High Explosives License Number Expiration Date <br /> ❑ CHP Hazardous Material Transportation for Explosives License Number Expiration Date <br /> ❑ San Joaquin County Sheriff-Coroner Explosives Application and Permit License Number Expiration Date <br /> ❑ California Occupational Safely 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 ❑ Other_ <br /> Well Log copy attached ❑ Yes �L No Grout Seal ❑ No ❑ Yes ft below ground surface(bgs) Hole Diameter_ inches <br /> Well Conductor Casing Yes ❑ No Depth of Conductor Casing It bgs Diameter of Conductor Casing inches <br /> r <br /> Well Casing Diameter Ir inches Total Depth 1t/tJ r ft Depth to Water_ .. ft Depth of Casing _ ft bgs <br /> DESTRUCTION SPECIFICATION <br /> Sealing Material fronm _ ft bus to V ft bgs Filler Material from ft bgs to _ <br /> Well casing to be perforated by one of the following methods; from ft bgs to�� O <br /> ❑ Mills Knife Number of cuts every ft and/or __ S , <br /> ❑ Explosives 1­1Detonating cord ❑ with projectiles every_ _ _ft ❑ without projectile F, 01 �Q <br /> ❑ Detonating cord and boosters ❑ with projectiles every ft ❑ without projectf / l/jQ(J <br /> ❑ Other _ 4471'o//A/ O(� <br /> Sealing Material Neat Cement(94 Ib bag/5-6 gal water) Sand Cement sack mix/1 gal water Benton it�RTMq� Y <br /> Pellets F <br /> Bentonite(20%solids) Manufacturer Spec%solids_% Name Specs on File Specs Submitted N <br /> Placement Method X Pumped Free Fall Other <br /> Seal Completion Complete with Mushroom Cap�1 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 DateCk(7 2 `t`I- <br /> k Area 'k <br /> Destruction InInspectionBy" (+ 1-VQDateu"1/ ZZ !/Z�1 Employee ID# <br /> e <br /> COMMENTS U *CIS GI` le <br /> PE Sc Received Checkli Amount Date Permit/ Invoice# Well ID# <br /> Codes info Cash Remitted Service Request# <br /> V 4'55 <br /> i <br /> 1773SSg2-� <br />