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WELL DESTRUCTION PERMIT PUBLIC WATER SYSTEM ❑ Yes ❑ No SAN JOAQUIN 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 CnY/ZIP N . ( CROSSSTREET tlRnj �EET f M _APN OW PARCEL SfZE)i Lppp�rNNND11 USE APPLICATION # 04 OWNER J V fJ5 1 j PHONE y011 4 OWNER ADDRESS '� 1 1Y Mk)O-" _ __ CITY/STATE/ZJP 11 1 I I� 1 CONTRACTOR ADDRESS r/ I C-57 WELL DRILLING LICENSE NUMBER PERFORATION CONTRACTOR PERFORATION CONTRACTOR ADDRESS ❑ C-57 Well Drilling ❑ Bureau of Alcohol, Tobacco and Firearms - Users of High Explosives ❑ CHP Hazardous Material Transportation for Explosives ❑ San Joaquin County Sheriff -Coroner Explosives Application and Permit ❑ California Occupational Safety Health - Blaster PHONE W 011. `b f f� (� Cj1I"' CIIWSTATE/ZIP 1 " tO"['+ �j , , R J r 1 EXPIRATION DATE CITY/STATE/ZIP License Number License Number License Number License Number License Number Expiration Date Expiration Date Expiration Date REASON FOR DESTRUCTION A Dry ❑ Replacement Well ❑ Caved In ❑ Pit Well ❑ Inactive ❑ T2trF�dl6,� Detected/Suspected Well Water Contaminants) __.___..vVr Adjacent propertywith contamination (Address) Known Soil/Water contaminants at adjacent property EXISTING WELL CONSTRUCTION DETAILS ❑ Open Bottom %4 Gravel Pack ❑ Uncased ❑ Others'o)L Well Log copy attached ❑ Yes Z`Q/No Grout Seal ❑ No ❑ Yes ft below ground surface (bgs) Hole Diameter TNjF , inches Well Conductor Casing ❑ Yes Jis No Depth of Con or Casing It b Diameter of Conductor Casing- �w�nches Well Casing Diameter II inches Total Depth ft Depth to Water_ �ft Depth of Casing _ ft bgs DESTRUCTION SPECIFICATION Sealing Material from _ �_ ft bgs to 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 ❑ 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_ Sealing Material Neat Cement (94 lb bagl5-6 gal water) Sand Cement sack mixIT gal water Bentonite Pellet Bentonite (20% loplete ds) Manufacturer Spec % solids % Name_ PI ement Method Pumped Free Fall j Seal Completion with Mushroom Cap ft bgs Specs on File G Specs Submitted Other Complete to Existing Surface Pad MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS, CALL (209) 953-7697 FOR INSPECTIONS DEPARTMENT USE ONLY Application Accepted By K 5�-7-' �- Date_1 / Area G Destruction Inspection By / Date t Employee ID# Ffe� Yl l' (7 COMMENTS 44 WA- -i 0 C u PE SC Received CheckV Amount Da Codes Info By Cash Remitted I IF Permit/ Invoice # Well ID# Service Request # o EH23/21 2zx; � /,3 7 L 7�6( WELL DESTRUCTION PERMIT 11!23!21 9