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E AIL.ED <br /> A En <br /> Z - <br /> WELL DESTRUCTION PERMIT <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 <br /> rt 1 YEAR FROM DATE ISSUED <br /> JOB ADORESS ` �'/71 /� [�.� , C[TYRIP�\nQ. rra i q �1ji q- r <br /> CROSS S-T�RTE\EyTT MIh nAl I T W' APN - PARCEL SizJ]'�LAND USE APPLICATION# c <br /> OWNER M V �1J11 I Q� PHONE ' 1�q(Z(_I 'I��Uct/ T <br /> OWNER ADDRESS Z� Z CITY/STATE/ZIP �S C/a I N c�� iZD J <br /> CONTRACTOR M \`s %01 1 N �`7��J{fit/ PHONE IM 5LZ- 1 n I r <br /> CONTRACTOR ADDRESS im R I WSJ W t J�{ �J CITY/STATE/ZIP tJU.C��/y�� f r, <br /> C-57 WELL DRILLING LICENSE NUMBER U Ui`0 lk 2Z ExPIRATION DATE <br /> PERFORATION CONTRACTOR PHONE <br /> PERFORATION CONTRACTOR ADDRESS CRY/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 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 Conductor Casing ft bgs Diameter of Conductor Casing inches <br /> Well Casing Diameter A__—inches Total Depth �ft Depth to Water ft Depth of Casing_ ft bgs <br /> DESTRUCTION SPECIFICATION rr I <br /> Sealing Material from ft bgs to,� ; 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 ft ❑ without projectile <br /> ❑ Other <br /> Sealing Material Neat Cement(94 lb bag/5-6 gal water) Sand Cement sack mixll gal water Bentonite <br /> Pellets <br /> P 46Bentonite(20%solids) Manufacturer Spec%solids % Name Specs on File _ Specs Submitted <br /> ement Method Pumped I Free Fa Other <br /> Seal Completion Lplete with Mushroom Cap i ft bgs Complete to Existing Surface Pad <br /> MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS, CALL(209)953-7697 FOR INSPECTIONS <br /> 9 � DEPARTMENT USE ONLY <br /> Application Accepted By ��""� Date F ?-,S— Area s <br /> Destruction Inspection By / !/ Date V� 4S 6�7 Employee ID# <br /> COMMENTS AXE ✓tGLL /�l}L 3 7 z. <br /> i <br /> q <br /> PE SC Received Check#/ Amount Date Permit/ I e# ti Well ID# <br /> Codes Info By Cash Remitted Service Request# T <br /> E D 42-08 / 6 �' `� /ELL Ut51 HUG IUN PERMIT <br /> ' <br /> Uploaded into Accela <br />