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WELL DESTRUCTION PERMIT PUBLIC WATER SYSTEM ❑Yes ❑No SAN JOAOUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 East Hazelton Avenue-STOCKTON CA 95205 - (209)468-3420 NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS CITY/ZIP +�1� � CROSS STREET , ,f APN LiCJ� �-13— 4!9,5_0 PARCEL SIZE '9ZAND USE APPLICATION# o OWNER Ji,"110JL C Jg/kw / f� PHONE OWNER ADDRESS L fI/N ��r CITY/STATE/ZIP CONTRACTOR 1/t [.{ C IY / PHONE ^0 2"75 ' CONTRACTOR ADDRESS / ^ CITY/STATE/ZIPa&y'Z�`�/d/I!,/./ G ��rG C-57 WELL DRILLING LICENSE NUMBER EXPIRATION DATE —JF IF �JFF sl' PERFORATION CONTRACTOR 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 Dat ❑ CHP Hazardous Material Transportation for Explosives License Number Expiration Da 4 ❑ San Joaquin County Sheriff-Coroner Explosives Application and Permit License Number Expiration Date ry ❑ California Occupational Safety Health-Blaster License Number Expiration REASON FOR DESTRUCTION 'PK Dry ❑ Replacement Well ❑ Caved In ❑ Pit Well ❑ Inactive 3,qTest 141 Detected/Suspected Well Water Contaminant(s) �O�0, rlp ( Y Adjacent property with contamination(Address) ( ON CO Known Soil/Water contaminants at adjacent property 'bq A� 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.It Depth to Water ft Depth of Casing ft bgs DESTRUCTION SPECIFICATION Sealing Material from ft bgs to _ ft bgs Filler Material i 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 ft and/or ❑ Explosives ❑ Detonating cord ❑ with projectiles every ft ❑ without projectile ❑ Detonating cord and boosters ❑ with projectiles every ft ❑ without projectile ❑ Other iC S Sealing Material Neat Cement(94 Ib bag/5-6 gal water) Sand Cement sack mixll gal water X71 Bd"JOe/�,Pellets Bentonite(20%solids) Manufacturer Spec%solids_ % Name i Specs on File Specs Submitted Placement Method Pumped Free FII 1 Other Seal Completion /N Complete with Mushroom Cap ft bgs i Complete to Existing Surface Pad 1 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. is MINI M HOUR AD NC NOTICE REQUIRED FOR INSPECTIONS CONTRACTORS SIGNATURE TITLE C ATE f I_ _ St. » ....,. f _. _. _ . ............................ .................. ............ .......... ............ 17 3 mmw . . 11 WN 1 f �� ........................ ........ ...................... �_. , ......... b pEFARTMENT USE ONLY I Application Accepted By 1 Date Area r ( Em to ee ID# v Destruction Insp ction By ^ Date p y COENTS [ 4 N tv-u ;S v t/1fitjwpy- -7-0 PE SC Received QhCrato Amount Date Permit/ Invoice# Well IDrf 'C Codes Info B Cash Remitted Service Request# EHD 43-08 WELL DESTRUCTION PERMIT 4/30/12