Laserfiche WebLink
WELL DESTRUCTION PERMIT <br /> PUBLIC WATER SYSTEM DyesAd <br /> No i <br /> t <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE 3"'FLOOR-STOCKTON CA 95202 - (209)468-3420 <br /> NON-REFUNDABLE,PERMIT - CALL(209)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS �• N —021-0I CITY/ZIP ni <br /> rJ 4 PHONE — r o <br /> OWNER 10 C <br /> "{ I CITY/STATE/ZIP F <br /> OVI'NER ADDRESS <br /> CONTRACTOR [� � ���, -� UIAIZ:� �j�j��JC� PHONE_ P ��7J/—� - <br /> CONTRACTOR ADDRESS 306 S J019RVy�7 ICJI CITY/STATEIZIP v <br /> WELL DRILLING LICENSE NUMBER �c3 _ EXPIRATION DATE —ac <br /> 6 <br /> PERFORATION CONTRACTOR PHONE d 77 r7 )57 <br /> PERFORATION CONTRACTOR ADDRESS <br /> ❑ C-57 Well Drilling Liceitm irat D t <br /> Number E;c ira ion to <br /> ❑ Bureau of Alcohol,Tobacco and Firearms-Users of High Explosives License �-��P#_�� `�1 ,�r--- <br /> ❑ CHP Hazardous Material Transportation for Explosives License l�lt may hallo xp+i tdM t at <br /> ❑ San Joaquin County Sheriff-Coroner Explosives Application and Permit Licens biff{er �¢( � <br /> ❑ California Occupational Safety Health-Blaster' <br /> LicenseNiimbertrig <br /> E ti ate' <br /> REASON FOR DESTRUCTION ❑ Dry ❑ Replacement Well ❑ Caved In �N Pit Well <br /> _ _--_E]0I etive ElTest Hole <br /> Detected!Suspected Well Water Contaminant(s): <br /> Adjacent property with contamination (Address): <br /> k Known Soil I Water contaminants at adjacent property: <br /> EXISTING WELL CONSTRUCTION DETAIILSS Open Bottom ❑ Gravel Pack ❑ Uncased Other ILtNliUGILI.f_ll/ <br /> Well Log copy attached ❑ Yes No Grout Seal ❑ No ❑ Yes ft below ground surface(bgs) Hole Diameter inches <br /> Well Conductor Casing ❑ Yes kY<o Depth of Conductor Casing ft bgs Diameter of Conductor Casing _inches <br /> Well Casing Diameter_4__inches Total Depth yg ft Depth to Water 14' —ft Depth of Casinpli •+N ft bgs r <br /> DESTRUCTION SPECIFICATION h <br /> k Sealing Material from C) __ft bgs to _ftbgs Filler Material from ft bgs to ft bgs <br /> IWell casing to be uerforated by one of the following methods from ft bgs to ft bgs F <br /> I ❑ Mills Knife Number of cuts every ft and 1 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 />( Sealin aterial ❑ Neat Cement(94 lb bug/5-6gal water) ❑ Sand Cement sack mix l 7 gal water ❑ Bentonite Pellets <br /> r Bentonite(20%solids ❑ Manufacturer Spec%solids % Name a__<Pecs on File 13 Specs Submitted_ G <br /> Placement Method Pumped ❑ Free Fall ❑ Other <br /> Seal Completion: ❑ Complete with Mushroom Cap ft bgs ❑ Complete to Existing Surface Pad <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> e <br /> MININ H UR ANCE NOTICE REQUIRED FOR SPECTIONS <br /> Ad <br /> CON-TRACT S SIGNATURE: TITLE' DATE:.� �.` s-DE=PA-RIME-NT-USE-OAl1.;Y°�"-:' S- <br /> Application Accepted By Date j Area r' 3 iy t <br /> Destruction Inspection By Date Employee 1D# 4_15 <br /> COMMENTS <br /> ig <br /> r <br /> f <br /> PE SC Received Che Amount Permitl <br /> Codes Info B Cash Remitted Date Service Re nest# Invoice# Well ID# <br /> I <br /> 3485 rso.r>v �� D _ Z <br /> EHD 43-02-OOs A A `- <br /> 61VO4 Wcil Dcs1ruclion Permitum�ddcrt��-04 <br /> .e f�� <br />