WP2501316 - Laserfiche WebLink

Home Browse Search

, r WPM mm=E® WELL DESTRUCTION PERMIT PUBLIC WATER SYSTEM ❑Yes ❑No \2 A' S OAOUIIV OUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 East Hazetton Avenue-STOCKTON CA 95205 - (209)468-3420 NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS 2Q-+' DRQNZAN P2 d �j1{�j�, CITY/zIP IY aN t�/LGV 11�2� CROSS STREET Y I U APN I 1 �l 2 i W�/ PARCEL SIZE�j,QLAND USE APPLICATION# y OWNER N V- PHONE Ny) ILt"IA _C�i- 1`1V )- z OWNER ADDRESS 23 t&'ntte'd Dr. y� /' CrTY/STATTJZIPy�G1� 1 •N YV \i� 611✓f-3� CONTRACTORMaW l 1 II 1 1 d V PHONE ?Gq 51L-2D, 1q Z(`�U+ C� CONTRACTOR ADDRESS I l �)% CRY/STATE/ZIP O(O M V Ul d✓3 ci 7 C-57 WELL DRILLING LICENSE NUMBER��ZZ EXPIRATION DATE 04 3 C. 20 PERFORATION CONTRACTOR PHONE PERFORATION CONTRACTOR ADDRESS CRY/STATE/ZIP ❑ C-57 Well Drilling License Number Expiration Date ❑ 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 ❑ California Occupational Safety Health-Blaster License Number Expiration D REASON FOR DESTRUCTION Dry ❑ Replacement Well ❑ Caved In ❑ Pit Well Inactive ❑ Te flI1ffEF1V Detected/Suspected Well Water�ontaminant(s) Adjacent property with contamination(Address) Known Soil/Water contaminants at adjacent property _ Q_il__�_ EXISTING WELL CONSTRUCTION DETAILS ❑ Open Bottom Gravel Pack ❑ Uncased ❑ Other 11O Well Log copy attached ❑ Yes ❑ No Grout Seal ❑ No ❑ Yes ft below ground surface(bgs) Hole R Tr Well Conductor Casing LI v_- ❑ No Depth of Conduc or Casing ft bgs Diameter of Conductor Ca Well Casing Diameter_�11 inches Total Depth�ft Depth to Water 7 U ft Depth of Casing 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___ .._.. Pellets ling Material Neat Cement(94 lb bag/5-6 gal water) I Sand Cement sack mix/7 gal water Bentonite Bentonite(20%solids) Manufacturer Spec%solids % Name Specs on File Specs Submitted Placement Method � Pumped Free Fall Other Seal Completion Complete with Mushroom Cap ft bgs 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 � '� Date ��-' zS- Area ,,4ec 11 Destruction Inspection By� - `�'' Date 7-' Employee ID# AS COMMENTS � ' x l� PE SC Received Check#/ Amount Date Permit/ Invoice# Well ID# Codes Info B Cash Remitted Service Request# 372 l(ol u da (1.1a•2 Pas 3 EHD 43-08 �-2-2- '�� WELL DESTRUCTION PERMIT 11;23,2, Uploaded into Accela