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t V. E"AI EDSUi;110t�, 111- 2- 2 CPUBLIC WATER SYSTEM ❑Yes ❑No SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1668 East Hazelton Avenue-STOCKTON CA 95205 - (209)468-3420 NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED 1' I 1' cITY/zIP� ,�i tQN C �i x(5-215 JOB ADDRESS CROSS STREET �'/ \ APN '�'"t- l/ I�/ - J PARCEL SIZE LAND USE APPLICATION# C '1 I/� _ C OWNER t 1 r 1, J v\1/ PHONE -2.01 i�-10& 31110-7 OWNER ADDRESS V L1 S S , CITY/STATE/ZIP MU l/t C� SCA q J 1 I CONTRACTOR II� �r�,y-�� t(r t J PHONE 2 (�;21 (1 612--fit /� /� (� �7 CONTRACTOR ADDRESS I'� r1�L' V�7 I (} CITY/STATE/ZIP IYi00A )�j\1 �/, rl( A "t D �% / �` C-57 WELL DRILLING LICENSE NUMBER �i�� "l� �� ExPIRATION DATE PERFORATION CONTRACTOR PHONE PERFORATION CONTRACTOR ADDRESS CITY/STATE/ZIP ❑ C-57 Well Drilling License Number Expiration Date i ❑ Bureau of Alcohol,Tobacco and Firearms-Users of High Explosives License Number Expiration Date ❑ CHP Hazardous Material Transportation for Explosives License Number Expiration Date_ ❑ San Joaquin County Sheriff-Coroner Explosives Application and Permit License Number Expiration Date OA ❑ California Occupational Safety Health-Blaster License Number Expiration Date r�l N r REASON FOR DESTRUCTION ❑ Dry ❑ Replacement Well ❑ Caved In ❑ Pit Well Inactive ❑ Test Hole 'ICD Detected/Suspected Well Water Contaminants) Adjacent propertyvnth contamination(Address) 2®21j Known Soil,'Water contaminants at adjacent property -_- -- __- AN J04 1' EXISTING WELL CONSTRUCTION DETAILS ❑ Open Bottom Gravel Pack ❑ Uncased ❑ Other T'-f 664��I �Ty Well Log copy attached ❑ Yes ❑ No Grout Seal ❑ No ❑ Yes _ ft below ground surface(bgs) Hole Diameter Inches ENT Well Conductor Casing ❑ Yes ❑ No Depth of ConduGta` Casing ft tics Diameter of Conductor Casing inches Well Casing Diameter_ _ inches Total Depth Vft Depth to Water ft Depth of Casing ft bgs DESTRUCTION SPECIFICATION Sealing Material from O ft bgs to ftbgs 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 everyft ❑ without projectile ❑ Detonating cord and boosters ❑ with projectiles every_ ft ❑ without projectile ❑ Other__. - - ------ __ - � Sealing Material Neat Cement(94 lb bag/5-6 gal water) Sand Cement sack m&7 gal water Bentonite Pellets Bentonite(20° solids) Manufacturer Spec%solids % Name Specs on File Specs Submitted Place ent Method Pumped Free Fall ---7j Other Seal Completion o plete with Mushroom Cap `S� ft bgs Complete to Existing Surface Pad MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS, CALL(209)953-7697 FOR INSPECTIONS l _ _DEPARTMENT USE ON Application Accepted By5 /7 _ Date Area Destruction Inspection 13 Date 717, 9 Employee IDR COMMENTS C 4-0 PE Sc Received Check#/ Amount Date Permit/ Invoice Well ID# Codes Info By Cash Remitted Service Re uest# 1373 !V 6�- /9s :T�Z 1 124 Of eo 5-3 8=s — ifbX. . -417YS93 5-&5