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�MA ELL 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 FR?OM DATE ISSUED JOB ADDRESS "J 1 •� CITYIZIP SCr��N CIA 1 l�/_0 �'i.•, CROSS STREET (• �`�I APN PARCEL SIZE/,1�/�y LAND USE -APPLICATION# OWNER M y ��c (� PHONE OWNER ADDRESS 1'0 A-1 B�,�'��jj J ('w` CrTYISTATE/ZIIP(� G 'jl �� -ZQ CONTRACTOR `` 1�Y 1V PHONE L V-1 L+� Zlb A r CONTRACTOR ADDRESS��` 1t/UY J CITY/STATEIZIP C-57 WELL DRILLING LICENSE NUMBER EXPIRATION DATE V 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 Date ❑ CHID Hazardous Material Transportation for Explosives License Number Expiration Date ❑ San Joaquin County Sheriff-Coroner Explosives Application and Permit License Number Expiration Date ❑ California Occupational Safety Health-Blaster License Number Expiration Date REASON FOR DESTRUCTION ❑ Dry ❑ Replacement Well ❑ Caved in ❑ Pit Well ❑ Inactive ❑ 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 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 ❑ ❑ No Depth of Conductor Casing ft bgs Diameter of Conductor Casing inches Well Casing Diameter— es inches Total Depth It Depth to Water ft Depth of Casing ft bgs DESTRUCTION SPECIFICATION {� Sealing Material from _O_ __ft bgs to_154_.ft bgs Filler Material from ft bgs to It bgs Well casing to be perforated by one of the following methods: from It 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 Ib 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 Pumped Free Fall Other Seal Completion omplete with Mushroom Cap it has I 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 Jt/�3{sf'/w� Date 7 ZOL.f Area Q Destruction Inspection By Date �/Z!Z5 Employee ID# COMMENTS PE SC Received Check#1 Amount Date Permit/ `Sq�nvoice# ell ID# Codes Info B Cash Remitted Service Request# 37w /(2/ WP25001 )Z �►� v�N O f H� EH23121 C r ? w �� b p loaded into Accel ESTRUCTION PERMIT t 1l23/2'I