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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 (2091953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS W06iiW141q0tWOL-7 CITYRIP• C ` ) C45 CROSS STREET A91 ZI � C� Z I A�/< APN _�y/ 3 �U' J'( PARCEL SIZE?L'S Z LAND USE APPLICATION # OWNER /\ n� L ` PHONE f `� /`� OWNER ADDRESS O O X / CITY/STATE7/Z/IP k OG I4 CONTRACTOR 4 /r4 10R. Ir I< 6,, _EAG PHONE CONTRACTOR ADDRESS --300 S' Y.14!" CITY/STATE/ZIP/1P a OG qCA U/ C-57 WELL DRILLING LICENSE NUMBER L�� / EXPIRATION DATE -f--3U3 1-1 ` PERFORATION CONTRACTOR l^ o ! 1 C�r-> PHONE h 1- 7 - 7/ 0 I q PERFORATION CONTRACTOR ADDRESS / e> CITY/STATE/ZIP 0 (A / 6 0 ,C-57 Well Drilling License Number Ex ira g•on Dat ' Ck"BUreau of Alcohol, Tobacco and Firearms -Users of High Explosives License Number Q_eA -/Y3'•g,3 Expira ion Y7 :Z0 fa, -'CHP Hazardous Material Transportation for Explosives License Number /37 Gf 1 Expiration Date ❑ San Joaquin County Sheriff -Coroner Explosives Application and Permit License Number / % - lO42- Expiration Date ❑ California Occupational Safety Health - Blaster License Number Expiration Date REASON FOR DESTRUCTION ❑ Dry ❑ Replacement Well ❑ Caved In ❑ Pit Well nactive ❑ 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 19'*Gravel Pack ❑ Uncased ❑ Other OT"' Well Log copy attached ❑ Yes O No Grout Seal ❑ No ❑ Yes S'45 rr fl below ground surface (bgs) Hole Diameter y inches Well Conductor Casing ❑ Yes ❑ No Depth of Conductor Casing _ ----ft bgs Diameter of Conductor Casing inches Well Casing Diameter / yZ" inches Total Depth _ ��fl Depth to Water hod It Depth of Casing It bgs DESTRUCTION SPECIFICATION SealingMaterial from __ /np_._ ft hgc; to d_._. it b Filler Material A.* CIZ4 v t z J bgs from �ft bgs to /�bo 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 it and/orv 27 Zi- Explosives O�Detonating cord CA, with projectiles every ft ❑ without projectile `/,� Det ati g cor and booster _ ❑ with projectile ev _ ft ❑ without projectile 11i JA, ❑ Other PelilrAA <1 4 E 6;K Sealing Material Neat Cement (94IAag15-6 gal water))t Sand Cement sack mix17 gal water Bentonite Pellets Bentonite (200/o solids) Manufacturer Spec % solids_. __.._ % Name Specs on File Specs Submitted Placement Method )C Pumped Free F all, Other Seal Completion k Complete with Mushroom Cap -1Y " U pts ��eft 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 WS. NINKJ-424,HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIO S CONTRACTORS SIGNATURE NT Application Accepted By _ Destruction Insp1e'cti, n COMMENTS `�`" �' r6.V-IA "L TITLE )QrA, ks--t DATE � At ,.) ib .s a , � a adWA 9 PV PARTMENTUSE ONLY !_.- - -w-- Date a"�t� Area Date A Employee �j 2- S ..Q S r �.C'� isw � • QAC b Mtttttte SAN JOAOUIN OOUN� ENvt�OEPE �MEN1 S ) rte,) 4C C. -I PE Codes Sc Info Received B Check#/ Cash Amount Remitted Date Permit/ Service Request # Invoice # Well ID# 43x4 b5 301-- 11L. -117 U(>003 -r717 EHD 43-08 WELL DESTRUCTION PERMIT 4/30/12