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l3a /or } - WELL DESTRUCTION PERMIT PUBLIC WATER SYSTEM ❑YcsodNo SAN JOAQUIN COUNTY ENVIRONMENTAL,HEALTH DEPARTMENT 304 E WEBER AvE 3"°FLOOR-STOCKTON CA 95202 - (209)468-3420 NON-REFUNDABLE.PERMIT CALL(209)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED n lOB ADDRESS "N ' �' —� t—UI CITYIZIP M y OWNER•097y& V PHONE d _ } �/} f. CITY/STATE/ZIP OWNER ADDRESS 1` t7X �0r/ — `CONTRACTOR II k.LI 7 PHONE CONTRACTOR ADDRESS G .I� CITYISTATEIZIP_�JC�f� 0-10C-57 ,� I 11d [;-S7 WELL DRILLING LICENSE NUMBER EXPIRATION DATE � PERFORATION CONTRACTOR II PHONE PERFORATION CONTRACTORADDRE�SS j � -- IT�ST EJ. IP �l tc❑ C-57 Well Drilling Lice s um r irat D t u ❑ Bureau of Alcohol,TA"cco and Firearms-Users of High Explosives License Number ; Egpira ion to ._ Ma � � ❑ CHP Hazardous Material Transportation for Explosives License�It11 fN t t I EU ❑ San Joaquin County Sheriff-Coroner Explosives Application and Permit Licens@ J*Jtt�b�er �, mm�l�i'P x��at� ecAe � ❑ California Occupational Safety Health-Blaster License umber ti sate' REASON FOR DESTRUCTION ❑ Dry ❑ Replacement Well ❑ Caved In N/Q1F1 well n Clive ❑ Test Hole i ui Detected/Suspected Well Water Co`taminant(s): Adjacent property with contamination (Address): Known Soil/Water contaminants at adjacent property: EXISTING WELL CONSTRUCTION DETAILS Open Bottom ❑ Gravel Pack ❑ Uncased Other Well Log copy attached ❑ Yes. F b ft No Grout Seal ❑ No ❑ Yes below ground surface(bgs) Hole Diameter inches " ; Well Conductor Casing ❑ Yes Depth of Conductor Casing ft bgs Diameter of Conductor Casing inches � Well Casing Diameter inches Total Depth tlN�l(i/ ft Depth to Water /de;�: ft Depth of Casing( .+✓ tt bgs DESTRUCTION SPECIFICATION r. Sealing Material from SPECIFICATION bgs to§f7XA ft bgs Filler Material from ft bgs to ft bgs p bgs well casing to be perforated by one of the following methods from ft to ft bgs_ g f_ J M Mills Knife Number of cuts every ft and/or ❑ Explosives ❑ Detonating cord: ❑ with projectiles every ft ❑ without projectile ❑ Detonating c�rd and boosters:- ❑ with projectiles every ft ❑ without projectile 0 Other etiliEnlon at Ce" t(941b b r/S-h gal water ❑ Sand Cement sack mix/7 ga]water ❑ Bentonite Pellets ID 0 olids 1 ufac pe o Sot s % e p on pe P e P edFr all ❑ Otcal ompls ap ompl ing rfa I HERY HAT I P AR IS AP (CATION A WO L BE DO 1 CCO N S JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS:,, 1 ALSO CERTIFY-THAT MY REQUIRED LICENSE IS CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION LAWS. MINI H UR ANCE NOTICE REQUIRED,FOR SPECTIONS ; r CONTRACT S SIGNATURE: TITLE- DATE: .r I' '' }' 1. I�. I 0 ;�4 tR i H� J tta .�...�EPA�'M°E-lY�'�5E--pNtY��»�.�_�_ .--,-=�-'. _--�t�-- ��-,� Application Accepted By F Date r Area 2— 1 F,r f Destruction Inspection By Date Employee ID# COMMENTS `JZ. it/lsT 'L�X7 ' , PE SC Received Che Amount Date Permit/ Invoice# Well ID# Codes Info By 11. Cash Remitted Service Request# '� ter I�34SS r o 00 C) Z - EHD 4342-009W ell Destruction Pcrmil Addendum 4604 Ic 6-8-04 6/7104 f.. Ff ff J