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WELL DESTRUCTION PERMIT ��ww PUBLIC WATER SYSTEM ElYe SAN JOAGUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 East Hazelton Avenue-STOCKTON CA 95205 - (209)468-3420 NON-REFUNDABLE PERMI CALL 209 953-7697 FOR INSPECTIONS dEXXP,.IIR�ES 1 YEAR FROM DATE ISSUED JOB ADDRESS 2 J CITY/ZIP r3'/"�✓ / S� CROSS STREET F N Z APN .- O PARCELS LAND USE APPLICATION# OWNERdLj /3E/7409;1,' /f i�N /�� rn a / , X105— �1 m OWNER ADDRESS /f .;F N G �+�� -e-CITY/STATE21P CONTRACTOR /� �6�Y//�S ,� /yl.�"" PHONE �CrJ [jy� CONTRACTOR ADDRESS //zD �f�-L-CJS oy CITY/STATEIZIP �/� e�✓/T / ✓�� C-57 WELL DRILLING LICENSE NUMBER 0= EXPIRATION DATE /Z-3 PERFORATION CONTRACTOR C_ PHONE 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 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 Contam' ant(s) Adjacent property with contamination(Address) Known Soil/Water contaminants at adjacent property EXISTING WELL CONSTRUCTION DETAILS /JW Open Bottom [IGravel Pack 11Uncased ❑ Other Well Log copy attached ❑ Yes ❑ No Grout Seal ❑ No ❑ Yes ft below ground surface(bgs) Hole Diameter inches Well Conductor Casing ❑,,,Y/es ❑ No Depth of Conductor Casing ft bgs Diameter of Conductor Casing inches 1 Well Casing Diameter �rl inches Total Depth(/eft¢ Depth to Water- ft Depth of Casing ft bgs DESTRUCTION SPECIFICATION 1 / Sealing Material from 1 k ft bgs to 0 ft bgs Filler Material from ft bgs to ft bgs Well casing to be perforated by one of the following methods: from It bgs to It bgs ❑ Mills Knife Number of cuts every ft and/or ❑ Explosives ❑ Detonating cord ❑ with projectiles every ft ❑ without projectile ❑ Detonating cord and boosters ❑ with projectiles every It ❑ without projectile ❑ Other Sealing Material 11 Neat Cement(94 Ib bag/5-6 gal water)❑ Sand Cement I&a-5 sack mix//gal water Bentonite Pellets Bentonite(20%solids) ,i Manufacturer Spec%solids_°/ Name n Specs on File Specs Submitted Placement Method I i Pumped ❑ Free Fall f I I Other 's ' �f� Seal Completion Complete with Mushroom Cap -- ft bgs Complete to Existing Surface Pad I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I 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. Fi� ANCE NOTICE REQUIRED FOR INSPECTIONS CONTRACTORS SIGNATURE TITLE ATE 4 - i r kl�a ti o e� J. V, _ _ 1 y' [V 4X 41 Act -"i oQQ�o , s ........ \DEPARTMENT USE ON Y Application Accepted`tdyL_ . A IU1'� _ Date Area Destruction Inspection By � pq Date Employee ID# COMENTS Sl�/F � S /f� Z MI te7 ; srVf --p�cx-71 T zl�� PE SC Received Check#/ Amount Parm iU Codes Info B Cash Remitted Date Service Re uest# Invoice# Well ID# 15" (9-7 Ofl 6 6070 -7 S EHD 43-08 WELL DESTRUCTION PERMIT 4/30/12