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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-RFFUNDARLF PERMIT CALL (209) 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS_ ��d�(,�C1L ��L� _ CITY/ZIP y,I// C , CROSS STREET A APN 5// 3,? a S9 PARCEL SIZE NS -SAND USE APPLICATION #_ �2 dd OWNER 11 A4,14 PHONE Permit/ Service Request # 7-(, Be1)J 9S3 OWNER ADDRESS CITY/STATE/ZIP `-,4. ffc� CONTRACTO PHONE CONTRACTOR ADDRESS � S, b _y2 �- CITY/STATE/ZIP' e C ce. ?i3 oQ Cl 0--l'C-57 WELL DRILLING LICENSE NUMBER �� 7 2 O EXPIRATIONDAATE V/ - 31 PERFORATION CONTRACTOR -7 6 PHONE ,' S y� 6 PERFORATION CONTRACTOR ADDRESS CITY/STATE/ZIP ID C-57 Well Drilling License Number JYExpiration 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 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 Id-Uravel Pack ❑ Uncased ❑ Other Well Log copy attached ❑ Yes OV No Grout Seal ❑ No ❑ Yes __!;�_ It below ground surface (bgs) Hole Diameter -/I" _ inches Well Conductor Casing ❑ Yes 0" No Depth of Conductor Casing -.______— __ft bgs Diameter of Conductor Casing _ inches Well Casing Diameter____ inches Total Depth _2g:P'O_ It Depth to Water___ ft Depth of Casing ._ It bgs DESTRUCTION SPECIFICATION y 104Zb, 4?07� GRA�� / Sealing Material from _/_C 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 It bgs ft bgs ❑ Mills Knife Number of cuts every fl 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) Tff�t _ sack mix/7 gal water Bentonite Pellets A Bentonite (20% solids) 1 Manufacturer Spec % solids % Name_ _ _ Specs on File Specs Submitted Placement Method // Pumped Free Fall I Other Seal Completion X Complete with Mushroom Cap ft 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,LAWS. I U 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS G CONTRACTORS SIGNATURE. PTITLE A we 6f DATE 2 �a PAY IMIF- )dT wE ko SAN.JOAQUIt! COUN 8WRONMENTAL - HEALTH DEPARTME T;, DEP A R T M E 14 T USE ONLY Application Accepted By. _ _ __ Date 11. 2-G' / 7- Area A h C C 0 Destruction Inspection By Date 17, ZZ L 11 Employee ID# Ak me COMMENTS Iajq/r e ((;yr/ CL, l) 4(-- (-1,of 4 e fovAn (CYY7rn) +G h Pn lori4e. Vo�low-wP 4,r hiokA-e%. ip Irno Nee -6A — Zuw. �PE I Codes SC Info Received B Check#/ Cash Amount Remitted Date Permit/ Service Request # Invoice # Well ID# i EHD 43-08 WELL DESTRUCTION PERMIT 4/30/12