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," a C-)M WELL DESTRUCTION PERMIT 2 PUBLIC WATER SYSTEM [I Yes ❑No SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 East Hazelton Avenue-STOCKTON CA 95205 - (209)468-3420 NON-REFUNDABLE PERMIT M(� CALL 209 953-7697 FOR INSPECTIONS / EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS V,1 CrrY21P y VJ•/�7 CROSS STREETUH y ktff 1 fNV' APN Ift ` PARCEL SIZIE � LAND/U�SE ApfLLLIIICA7740 TION1#� r OWNER V T 'll S '1 PHONE_ {/ "t' ""/ 17 U r ��0 �� CirrY/STATE/ZIP V 1 �/_ CG� q 0 1;/l�tJ J OWNER ADDRESS 1 ^ /{ CONTRACTOR �}Y1�`lI�1 - PHONE nR ✓1(l'i�/ , r1!(/�W/�r'J�� CONTRACTOR ADDRESS Y1 ` CrTYISTATE/ZIP 'fntc1U.]� llVc I�!'/ 7 y� C-57 WELL DRILLING LICENSE NUMBER ExPIRATioN DATE PERFORATION CONTRACTOR PHONE PERFORATION CONTRACTOR ADDRESS CITY/STATEIZIP -i C-57 Well Drilling License Number '\,1 1i Expiration Dat ❑ Bureau of Alcohol,Tobacco and Firearms-Users of High Explosives License Number Expiration Date ❑ CHP Hazardous Material Transportation for Explosives License Number Expiration Date ❑ San Joaquin County Sheriff-Coroner Explosives Application and Permit License Number Expiration Date ❑ California Occupational Safety Health-Blaster License Number Expiration Date REASON FOR DESTRUCTION ❑ Dry ❑ Replacement Well ❑ Caved In ❑ Pit Well Inactive ❑ Test Hole Detected/Suspected Well Water Contaminant(s) Adjacent property with contamination(Address) Known SoiLWater 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' ft Depth to Water ft Depth of Casing ft bgs DESTRUCTION SPECIFICATION Sealing Material from SPECIFICATION bgs to ft bgs Filler Material from _ft bgs to__ ____ft bgs ell casing to be ep rforatnd by one of the following method from It bgs to ft bgs Mills Knife _Number of cuts every_ I ft and/or ❑ Explosives ❑ Detonating cord ❑ with projectiles every it ❑ without projectile ❑ Detonating cord and boosters ❑ with projectiles every it ❑ without projectile ❑ Other Sealing Material Neat Cement(94 lb bag/5-6 gat water) I Sand Cement sack mix17 gal water Bentonite Pellets Bentonite(20%solids) Manufacturer Spec%solids % Name Specs on File Specs Submitted Placement Method Pumped IFrees Fall i Other Seal Completion Complete With Mushroom Cap /, It bgs Complete to Existing Surface Pad MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS, CALL(209)953-7697 FOR INSPECTIONS DEPARTMENT USE ON /L Application Accepted By � �` -- Date Area Destruction Inspection By ` Dates, Employee ID# COMMENTS l/l/G� �� / - pit C4Si/t S / PE I SC Received Check#/ Amount Date PermiU Inv WellID# Codes Info By Cash Remitted Service Request# �l 7 /Co I T- 1-2 -2c EHD 43-06 (� �i � )C 1 " WELL DE6THUU1IUN PERMIT 11123121 Uploaded into Accela