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DATE /2' CONTRACTORS SIGNATURE H009,11ANCE NOTICE REQUIRED FOR INSPECTIONS rrY7-7'1Wr/j___ TITLE 7,fr PAYMENT - — RECEIVED DEC 2 4 2020 SAN JOAQUIN COUNIY - ENVIRONMENTAL - HEALTH DEPARTMENT DEPARTMENT USE ONLY Date /diC);0 Area Date \ ( Application Accepted By Destruction Inspection ByK (Sis-to").,N . Employee ID# D4 WELL DESTRUCTION PERMIT PUBLIC WATER SYSTEM 111 Yes SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 East HazeIton Avenue - STOCKTON CA 95205 - (209)468-3420 NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS 247.--)S ..S.- /31-:),T---/-2 „1—it--. ciTylzip 7-4,..- -.`1 5.77<Y CROSS STREET 14/1"71-P2 APN 1/47.—/".2z—zy PARCEL SIZE/ 77-LAND USE APPLICATION # OWNER AAI_A-14- A74-511/1.4')Z.- --- L'W - "-ki,k7: "P-41-11CeE 14 S- — • 5 - - is OWNER ADDRESS 7 7 .-:..,4,--. CITY/STATE/ZIP / CONTRACTOR 4 1 i A. I/ 'AtIPHONE 7 :"Tt CONTRACTOR ADDRESS 2-17Z) /4C--#Al I.,, • - -1) CITY/STATE/ZIP /IT '15-.0 ..(' 0 C-57 WELL DRILLING LICENSE NUMBER LI (' 7) (":"_ EXPIRATION DATE - PERFORATION CONTRACTOR PHONE PERFORATION CONTRACTOR ADDRESS CITY/STATE/ZIP 0 C-57 Well Drilling License Number Expiration Date 0 Bureau of Alcohol, Tobacco and Firearms - Users of High Explosives License Number Expiration Date 0 CHP Hazardous Material Transportation for Explosives License Number Expiration Date 0 San Joaquin County Sheriff-Coroner Explosives Application and Permit License Number Expiration Date 0 California Occupational Safety Health - Blaster License Number Expiration Date REASON FOR DESTRUCTION 0 Dry 0 Replacement Well 0 Caved In 0 Pit Well 0 Inactive 0 Test Hole Detected/Suspected Well Water Contaminant(s) Adjacent property with contamination (Address) Known Soil/Water contaminants at adjacent property EXISTING WELL CONSTRUCTION DETAILS Open Bottom 0 Gravel Pack 0 Uncased 0 Other ,fie Well Log copy attached 0 Yes 0 No Grout Seal 0 No 0 Yes ft below ground surface (bgs) Hole Diameter inches Well Conductor Casing 0 Yes 0 No Depth of Conductor Casing ft bgs Diameter of Conductor Casing _ inches Well Casing Diameter 3 4 inches Total Depth //5./11_-4t Depth to Water 75 ft Depth of Casing ft bgs DESTRUCTION SPECIFICATION Sealing Material from i r--.. ft bgs to D ft bgs Filler Material from ft bgs to ft bgs Well casing to be perforated by one of the following methods: from ft bgs to ft bgs 0 Mills Knife Number of cuts every ft and/or 0 Explosives 0 Detonating cord 0 with projectiles every ft 0 without projectile 0 Detonating cord and boosters 0 with projectiles every ft 0 without projectile 0 Other Sealing Material Neat Cement (94 lb bag/5-6 gal water) Sand Cement Mr -5 sack mix/7 gal water Bentonite Pellets Bentonite (20% solids) Manufacturer Spec % solids % Name _ Specs on File Specs Submitted Placement Method Pumped Free [all/ Other -/-711 277.7-7 F3e-r-fri/7 Seal Completion :Complete with Mushroom Cap ---3 f312/z_ 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. :SS311(1UV 11IS COMMENTS PE Codes SC Info Received Check#/ Cash , i Amount __Remitted Date Permit/ Service Jequest # Invoice # Well ID# CA 7 $ f., CIO 1 SW EHD 43-08 WELL DESTRUCTION PERMIT 4/30/12