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e <br />5 <br />WELL DESTRUCTION PERMIT <br />PUBLIC WATER SYSTEM ❑ Y -IM NO <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPT 1868 East Hazelton Avenue-STOCKTON CA 9520"232 - (20099) 458-3420 <br />NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS C\ J - % 6 <br />CITY/LP rr�/ `� , :5 D y <br />��-77,nn <br />CROSS STREET A APN ,2/o� "L X L1-- IS <br />PARCEL SIZ-4LAND UUSEE APPLICATION Ii <br />OWNER olk <br />PHONE ,'?6'J <br />OWNERADDRESS / i <br />� CITYISTATEI7JP -(` T- <br />. <br />CONTRACTOR / Y 11 <br />PHONE <br />/ <br />CONTRACTOR ADDR S / <br />CIY/STATE/2AP f <br />C-57 WELL DRILLING LICENSE NUMBER <br />ExPIRATION DATE <br />PERFORATION CONTRACTOR <br />PHONE <br />PERFORATION CONTRACTOR ADDREtS <br />CITY/STATEMP <br />.U- C-57 Well Drilling <br />License Number _5l Expiration Data 0� <br />Bureau of Alcohol, Tobacco and Firearms - Users of High Explosives <br />License Number Expiration Date <br />CHP Hazardous Material Transportation for Explosives <br />License Number Expiration Date <br />San Joaquin County Sherllf-Coroner Explosives Application and Permit <br />License Number Expiration Date <br />California Occupational Safety Health - Blaster <br />License Number Expiration Date <br />REASON FOR DESTRUCTION ❑ Dry ❑ Replacement WBII ❑ Caved In ❑ Pit Well ❑ Inactive Test Hole <br />Detected / Suspected Well Water Contaminant(Ii / <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___ <br />R below ground surface (logs) Hole Diameter inches <br />_ <br />Well Conductor Casing,9_Yss ❑ No Depth of Conductor CaNng 5"� ft logs Diameter of Conductor Casing inches <br />Well Casing Diameter /inches Total Depth c+�1_ ft Depth to Water / ft Depth of Casing / IT bgs <br />DESTRUCTION SPECIFICATION <br />Sealing Material from aoo it bgs to Q_ It bgs Filler Material <br />from __fl bgs to ft bps <br />Well casing to be perforated by one, of the following methods: <br />from ft bgs to ft bgs <br />❑ Mills Knife Number of cuts every ft and / or <br />❑ Explosives ❑ Detonating cord ❑ with projectiles every <br />_ _ ft ❑ vnttwut projectile <br />❑ Detonating cord and boosters ❑ with projectiles every <br />ft ❑ without projectile <br />❑ Other <br />Sealing Material Neat Cement (94 lb bag / 5-6 gal water) Sand Cement sack mix l7 gal water Bentonite Pellets <br />Bentonite (20% solids)M� dacturer Spec % solids _% Name <br />Specs on File Specs Submitted <br />Placement Method - Purtp�G i Free'. <br />Ciller <br />Seal Completion Co ustlroom Cap ft bgs <br />Complete to Existing Surface Pad <br />I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br />JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br />CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br />WORKERS COMPENSATION LAWS. <br />MI UM 4 HOUR DY E NOTICE REQUIRED FOR INSPE TIONS <br />CONTRACTORS SIGNATURE TILE % W %Q T AIN <br />—/ <br />yk <br />_. <br />_ <br />L 02018 <br />NV/,y <br />CSN <br />C <br />T— — T-- ya FNr Tr <br />_._— — --- --- - --7 r TiyENT <br />I <br />PAR MENT USE 0,N L/ n ,� <br />Mimi <br />M �IWAUM .•IIIa7aL <br />• I' <br />