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("N---10 a— R ejS1-i0 G-1 EHD 43-08 4/30/12 It LQ 69 WELL DESTRUCTION PEHMIT WELL DESTRUCTION PERMIT PUBLIC WATER SYSTEM L Yes LI No 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 FR JOB ADDRESS 237,- 1.0.......e4- ‘0444vi4..„._71-0 "RiA, ci-rwzip CROSS STREET /14.t '/ Am" APN , ..... , - PARCEL SIZE ._ LAND USE APPLICATION # OWNER (,,r.' ffeW A FaliTS I-IL PHONE i OWNER ADDRESS )0 iL 0 -fr I n )-y Pkt,-.) 1/ /4 1LI 0 CITY/STATE/ZIP `.7.7...Abi, k+) )1 (3.S.L1 / CONTRACTOR -Z, 4,693 fray- zl a,...-, PHONE 2- .0 1 - g z-7 — Fizo CONTRACTOR ADDRESS ia. 6 • 64- ,,-- /Si" cirdsTATE/zip 4111-36 . 1 4- 4 s'"--Z ,ri C-57 WELL DRILLING LICENSE NUMBER 441 /5 a-3 EXPIRATION DATE 7° - PERFORATION 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 Inactive 0 Test Hole s pr.- Detected/Suspected Well Water Contaminant(s) Adjacent property with contamination (Address) Known Soil/Water contaminants at adjacent property EXISTING WELL CONSTRUCTION DETAILS 0 Open Bottom 0 Gravel Pack 0 Uncased 0 Other 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 12, inches Total Depth 20 ft Depth to Water Lt ft Depth of Casing ft bgs _/ DESTRUCTION SPECIFICATION Sealing Material from 0 ft bgs to /.20 ft bgs Filler Material /,/,,z, 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 L 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 sack mix/7 gal water Bentonite Pellets Bentonite (20% solids) Manufacturer Spec % solids % Name Specs on File Specs Submitted Placement Method -I Pumped Free Fall n Other 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. Ift3 MINI UM:g2OUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS CONTRACTORS SIGNATURE TITLE DATE / - t —2o :SSiMUIV jji PE Codes SC Info Received By Check#/ Cash Amount Remitted Date Service Request # Permit/ Invoice # Well ID# q3 1/1 )41' WP 'V 'A- 4345 19--h(20 WPoo4t58 -, /34 rikt / 2020 AiirAflo Area Employee ID# e•trs) --- I - ! weA Application Accepted By Destruction Inspection By aeorv, COMMENTS U S E ONLY Date MA/ aC24; Date %4 041114 "Z- CiN 1.- • DEPARTMENT