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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-RFFIINDARLF PFRMIT CAI 1 (9(191 953-7F:97 Fnn IN1zDGL`TInA1C FYPIRGC I VCAD GDARA IIATc Iccimn JOB ADDRESS V -V V L CITY/ZIP CROSS STREET APN Cl - 1 PARCEL SIZES LAND USE APPLICATION # OWNER V `'Vr PHONE OWNER ADDRESS 42,- t CITY/STATE/ZIP �r r CONTRALTO v t ONE_______ I� CONTRACTOR ADDRESS W I b , , n7 -(a CITY/STATE/ZIP 1P � � C-57 WELL DRILLING LICENSE NUMBER EXPIRATION DATE PE FORATION CONTRACTOR PHONE PERFORATION CONTRACTOR ADDRESS C-57 Well Drilling CITY/STATE/ZIP License Number IM(,014 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 DETAILS ❑ Open Bottom ❑ Gravel Pack ❑ Uncased ❑ Other Well Log copy attached ❑ Yes No Grout Seal ❑ No ❑ Yes ___ It below ground surface (bgs) Hole Diameter inches Well Conductor Casing ❑ Yes No Depth of Con4I _ _ It bgs Diameter of Conductor Casing inches Well Casing Diameter_ inches Total Depth _ _ _ ft' epth to Water_ K L �Jft 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 It 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) i Sand Cement sack mix/7 gal water Bentonite Pellets Bentonite (20% solids) Manufacturer Spec % solids___ __% Name------- __ Specs on File Specs Submitted acement Method x, Pumped Free Fall Other Seal Completion / C_omplete with Mushroom Cap ft bgs Complete to Existing Surface Pad 1- 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. ti HOUR ADVANCE NOTICE REQUIRED FOR INS�PEfC IONS CONTRACTORS SIGNATURE TITLE �/ I ATE t _.. - j " s 44 EP RTMENT USE Lfl Application Accepted By�056Date Area Destruction Inspection By. + Date Employee ID# COMMENTS PE Sc Received Aec# Amount Permit/ Cods Info By Cash a itte Date Service Request # Invoice # Well ID# l .4, isof0kY 6 WPCL, 2L EHD 43-08 WELL DESTRUCTION PERMIT 4/30/12