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WELL DESTRUCTION PERMIT E��I�„E� PUBLIC WATER SYSTEM ❑Yes ❑No 5AN JOAOUIN C >n ONMENTAL HEALTH DEPARTMENT 1868 East HazeRon Avenue-STOCKTON CA 95205 -(209)468-3420 NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS N7--t 1(�1 v� FLA/ + CrtY21P Ma OCGa, UA CROSS STREET r� 1ry� ` I}Vyy�A�P/N�}� '1 t PARCEL SIZE 101 LAND (�USE APPLICATION 7#f n/}� y OWNERNV UUY l'11 I ��1r'vVII 1J 1I( —PHONE 00(/ )I t - uQ/ 1tU/00 z OWNER ADDRESS J 11tVd dO Of CITY/STATE/ZIP�1{+I�f"7��TOW G,A 1%.I J CONTRACTOR 111 Awn� /�JJ �,q�1 (I 1 1 ,{ a ��y,�� . PHONE 2,� 5a- I�t�VJ (,� CONTRACTOR ADDRESS JI I f t (r/tJf^"J Py nl CITY/STATE/ZIP {� `l Tj��7 tt C-57 WELL DRILLING LICENSE NUMBER "� �1C12Z EXPIRATION DATE PERFORATION CONTRACTOR PHONE PAV" . PERFORATION CONTRACTOR ADDRESS CITY/STATE/ZIP ❑ C-57 Well Drilling License Number Expiration Date ❑ Bureau of Alcohol.Tobacco and Firearms-Users of High Explosives License Number Expiration Iv/�+ ,may ❑ CHP Hazardous Material Transportation for Explosives License Number Ex p W10A;i;_iV-:N7'y e ` C 5 ❑ San Joaquin County Sheriff-Coroner Explosives Application and Permit License Number Expira I0)1iA.❑ California Occupational Safety Health-Blaster License NumberREASON FOR DESTRUCTION Dry ❑ Replacement Well Caved In ❑ Pit Well Inactive ❑ Test M Detected/Suspected Well Water Contaminant(s) Adjacent property with contamination(Address) Known SoiUWater contaminants at adjacent property _ EXISTING WELL CONSTRUCTION DETAILS ❑ Open Bottom Gravel Pack ❑ Uncased ❑ Other ___ Well Log copy attached ❑ Yes ❑ No Grout Seal ❑ No Yes - __ ft below ground surface(bgs) Hole Diameter inches Well Conductor Casing ❑ Yes ❑ No Depth of Conductor Casing ft bgs Diameter of Conductor Casing inches Well Casing Diameter inches Total Depth 05 it Depth to Water 2eu ft Depth of Casing _ _ It bgs DESTRUCTION SPECIFICATION fl Sealing Material from _ V- _ft bgs to l�-94__ It bgs Filler Material_ from ft bgs to ft bgs Well casing to be perforated by one of the following methods: from ft bgs to ft bgs ❑ Mills Knife Number of cuts every it and/or ❑ Explosives ❑ Detonating cord ❑ with projectiles every ft ❑ without projectile ❑ Detonating cord and boosters ❑ with projectiles every It ❑ without projectile ❑ Other Sealing Material Neat Cement(94 lb bag15-6 gal water) Sand Cement sack mix/7 gal water Bentonite Pellets Bentonite(20%solids) .. Manufacturer Spec%solids % Name Specs on File Specs Submitted Placement Method x Pumped Free all Other Seal Completion '� Complete with Mushroom Cap ft bgs Complete to Existing Surface Pad MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS, CALL(209)953-7697 FOR INSPECTIONS DEPARTMENT USE ONLY Application Accepted By / " Date //->L—Z0 Area at�t�tc�zt Destruction Inspection By f �/� Date r� 7 Employee ID# COMMENTS PE , SC Received Check#/ Amount Date Permit/ Invoice# Well ID# Codes Info B Cash Remitted Service Request# II 2•a 2 EHD43-08 WELL DESTRUCTION PERM17 11/23/21 Uploaded into Accela