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WELL DESTRUCTION PERMIT PUBLIC WATER SYSTEM ❑Yes ❑No SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 600 E MAIN STREET-STOCKTON CA 95202 - (209)468-3420 NON-REFUNDABLE PERMIT CALL(209)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR/FROM DATE ISSUED JOB ADDRESS g CITY/ZIP ��1 + CROSS STREET 1 Ctti �Il G�{,l AP 2-4 I /�1 L' 0�l 0 PARCEL SIZE V LAND USE APPLICATION# OWNER �� O 1 7 1. IWC PHONEVr�I!U!` I' OWNER ADDRESS 1 � r� CITY/STATE/ZIP I r V Iit�', ^{f CONTRACTOR �V I �!7� t t IN(,-, PHONE 1/L � ��'712 L �(I CONTRACTOR ADDRESS Ii � �'F� � CITY/STATE/ZIP �U:')Nle M,ACj C-57 WELL DRILLING LICENSE NUMBER a �// EXPIRATION DATE (.)` I PERFORATION CONTRACTOR PHONE PERFORATION CONTRACTOR ADDRESS CITY/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 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 ft below ground surface(bgs) Hole Diameter inches Well Conductor Casing ❑ Yes �7' No Depth of Conductor Casing ft bgs Diameter of Conductor Casing inches Well Casing Diameter_ P� inches Total Depth 'P-)0) ft Depth to Water ft Depth of Casing ft bgs DESTRUCTION SPECIFICATION Sealing Material fromft bgs to ft bgs Filler Material ^mom 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 everyft ❑ without projectile ❑ Detonating cord and boosters ❑ with projectiles everyft ❑ without projectile ❑ Other Sealing Material Neat Cement(94 Ib bag/5-6 gal water)7 Sand Cement sack mix/7 gal water X Bentonite Pellets Bentonite(20%solids) Manufacturer Spec%solids % Name Specs on File Specs Submitted Placement Method - Pumped Free Fall - 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. ) MINIMUM 2jtj-IOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS CONTRACTORS SIGNATURETITLE ^� 0'� r DATE - f PAYMENT DECEIVED rNik 19 2018 ,( SAN JOAQUIN COUNTY ENVIRONHEALTH D PART EM NT o �- r�. 0� � D A R T M ENT USE O N L Y c Application Accepted By Date - Area Destruction Inspection By ' ; ; Date �;11 4(,7 Employee ID#�� COMMENTS V { S YC V I Y c t. X4'1 rC'�1 " ,L PE SC Received Check#/ Amount Permit/ Codes Info B Cash emitte Date Service Request# Invoice# Well ID# ? 3 S'f 0 3g3-1 C EHD 43-08 WELL DESTRUCTION PERMIT 10/5/07