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WELL DESTRUCTION PERMIT <br />PUBLIC WATER SYSTEM 0 Yes 0 No <br />SAN JOAOUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT '1868 East Hazelton Avenue - STOCKTON CA 95205 - (209) 468-3420 <br />NON-RFFUNDARLF PFRMIT CAI 1 f9f191 953-7Rg7 FOR 1NCPF:rTIr1NS — FXPIPF-q I YFAn FRn11A r)ATr Iccimn <br />JOB ADDRESS <br />CITY/ZIP G <br />7 <br />S <br />CROSS STREET APNZ - <br />PARCEL SIZE LAND USE APPLICATION # <br />OWNER <br />PHONE 'c <br />1 <br />Well ID# <br />OWNER ADDRESS <br />CITY/STATE/ZIP <br />CONTRACTOR <br />PHONE <br />CONTRACTOR ADDRESS <br />CITY/STATE/ZIP <br />�J C-57 WELL DRILLING LICENSE NUMBER <br />_EXPIRATION DATE�� <br />PERFORATION CONTRACTOR <br />PHONE <br />PERFORATION CONTRACTOR ADDRESS <br />CITY/STATE/ZIP <br />❑ C-57 Well Drilling <br />License Number Expiration Date <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 Sheriff -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 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 ____ <br />ft below ground surface (bgs) Hole Diameter inches <br />Well Conductor Casing ❑ Yes No Depth of Conductor Casing _ _ __. _ ... .. <br />_ft bgs Diameter of Conductor Casing inches <br />Well Casing Diameter inches Total Depth qiD _ft Depth to Water ____ ft Depth of Casing It bgs <br />DESTRUCTION SPECIFICATION <br />Sealing Material from ft bgs to ft bgs Filler Material <br />from. _. ft bgs toft bgs <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 It and/or <br />❑ Explosives ❑ Detonating cord ❑ with projectiles every <br />- ft ❑ without projectile <br />❑ Detonating cord arid boosters ❑ with projectiles every <br />__ ft ❑ without projectile <br />❑ Other__ <br />Sealing Material Neat Cement (94 Ib bag/5-6 gal water) Sand Cement <br />------sack mixll gal water Bentonite Pellets <br />Bentonite (20% solids) Manufacturer Spec % solids _ Name <br />Specs on File Specs Submitted <br />Placement Method Pumped Free Fall <br />Other <br />Seal Completion Complete with Mushroom 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 COMPENSATI ISI LAWS. <br />MINI U 24 R DVANCE NOTICE REQUIRED FOR INSPE TIONS <br />CONTRACTORS SIGNATUR <br />Application Accepted By _ <br />Destruction Inspection By <br />COMMENTS <br />TITLE DATE <br />i <br />C4tA PY <br />3 115 EW1 <br />o&. 0 6 20 <br />2 AQ1J1N COU <br />�FALTH Al <br />p pA�� E <br />P_f1 43 <br />TMENT USE 0_14 L7 <br />lqgq <br />_ Date (� _ _ _ Area <br />Date_ Employee ID# <br />T <br />PE <br />SC <br />Info <br />Received <br />B <br />C <br />Cash <br />Amount <br />emitted <br />Date <br />Permit]Codes <br />ervice Re uest # <br />Invoice # <br />Well ID# <br />IbI <br />La 77 <br />s <br />V_ <br />1/ <br />EHD 43-08 WELL DESTRUCTION PERMIT <br />4/30/12 <br />