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C'I <br /> V <br /> EM�AI ELL D TRUCTION P RMIT <br /> G <br /> l ^ `0 a PUBLIC WATER SYSTEM ❑Yes Gil% <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 East Hazetton Avenue-STOCKTON CA 95205 - (209)468�3420 <br /> NON-REFUNDABLE PERMIT Al CALL 209 953-7697 FOR INSPECTIONS 1E�Xf�P�IR(E`S 1 YEAR/FROM DATE ISSUED <br /> JOa ADDRESS ^ ( /"�VDy- C"rZIP NI V <br /> CROSS STREET S S C APN V-2 0 PARCEL SIZE(c 3 LAND USE APPLICATION# <br /> OWNER PHONE Lkl� (1- �41 <br /> OWNER ADDREnS 1 N f`�j / CITY/STATE/ZIP Wamtcq /J r <br /> CONTRACTOR� a q-IAWAM 1 N v . PHONE � (1 qi,2—" I"L7-� -7� <br /> CONTRACTOR ADDRESS 11-1 1- li e-R l� 11 `t'(}��P CfTY/STATEIZIP NUN ,WN , CA 19f "/�7 <br /> C-57 WELL DRILLING LICENSE NUMBER U W WI2 EXPIRATION DATErJ` <br /> PERFORATION CONTRACTOR PHONE <br /> PERFORATION CONTRACTOR ADDRESS CrrY/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 Safety Health-Blaster License Number Expiration Date <br /> REASON FOR DESTRUCTION Dry ❑ Replacement Well ❑ Caved In ❑ Pit Well ❑ Inactive ❑ Test Hole <br /> Detected/Suspected Well Wat ontaminant(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 Conductor Casing ft b s Diameter of Conductor Casing _ inches <br /> Well Casing Diameter._inches Total Depth _�� It Depth to Water ft Depth of Casing_ _It bgs <br /> DESTRUCTION SPECIFICATION <br /> Sealing Material from ft bgs to_a_ 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 every____ft ❑ without projectile <br /> ❑ Detonating cord and boosters ❑ with projectiles every__ It ❑ without projectile <br /> ❑ Other <br /> Sealing Material Neat Cement(94 lb bag/5-6 gal wafer) Sand Cement sack mix/7 gal water Bentonite <br /> Pellets ,A, <br /> Bentonite(20°/a lids) Manufacturer Spec%solids % Name YV o 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 O L <br /> Application Accepted B 9 _ Date 2, / ZArea M lL Ati <br /> Destruction Inspection By Date Employee ID <br /> T T <br /> COMMENTS 3 &Aa5 k4c(� �C/�r -- <br /> SAN JCi <br /> ENVI _ .. .�n t T <br /> R <br /> PE SC Received Check#/ Amount Permit! <br /> Codes Info B Cash emitted Date Service Request# Invoice# <br /> � 1 <br /> i <br /> EHD43-08 C ZD�3�lQZ S Uploaded intC ACcela�'T <br /> 11123121 n <br />