WP0038050 - Laserfiche WebLink

Home Browse Search

WELL DESTRUCTION PERMIT • PUBLIC WATER SYSTEM ❑ Yes f fVo 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 DATE ISSUED 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 TA CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION LAy $ ff - `� .0, 14M 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS CONTRACTORS SIGNATU Application Accepted BY- Destruction Inspection By COMMENTS DEPARTMENT USE ONLY r7 Date 67 Date Area ID# rA PE SC In JOB ADDRESS CITY/ZIP ,,11 /��r!^^�� CROSS STREET N r APN2E5)- DD ; PARCEL SIZEeZ2LANQDSE�AAPPLIICATION # OWNER Y PHONE 1 O— V — ✓U7 OWNER ADDRESS CC;Dr CITY/STATE/ZIP CONTRACTOR NE Coo C76 CONTRACTOR ADDRESS I /STATE/ZIP C-57 WELL DRILLING LICENSE NUMBER `7 VK EXPIRATION DATE PERCONTRACTOR PHONE PERFORATION CONTRACTOR ADDRESS CITY/STATE/ZIP � C-57 Well Drilling License Numbe 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 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 DETAIL ❑ 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 ❑ Yes ❑ No Depth of Conductor Casing ft bgs Diameter of Conductor Casing inches Well Casing Diameter_ I inches Total Depth ft Depth to Water ft Depth of Casing ft bgs 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 Seal*g Material Neat Cement (94 Ib bag/5-6 gal water) i J Sand Cement sack mi�7 gal water i Bentonite Pellets 7 Bentonite (20% solids) 1 Manufacturer Spec % solids % Name i Specs on File Specs Submitted Placement Method Pumped F Free Fall I i Other Seal Completion 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 TA CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION LAy $ ff - `� .0, 14M 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS CONTRACTORS SIGNATU Application Accepted BY- Destruction Inspection By COMMENTS DEPARTMENT USE ONLY r7 Date 67 Date Area ID# rA PE SC In Received B Check#/ Cash Amount Remitted Date Permit/Codes Service Request # Invoice # Well ID# p Coo C76 &J I2, 16 Q,o�b EHD 43-08 WELL DESTRUCTION PERMIT 4/30/12