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WELL DESTRUCTION PERMIT P / f PUBLIC WATER SYSTEM [:]Yes d No SAN JOAOUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 East Hazelton Avenue - STOCKTON CA 95205 - (209) 468-3420 NON-RFFNNDARI F PFRMIT f_AI I l mQ1 Q53 -71;Q7 FnQ 1NCDPrTInAIC 1=YPIC21Z(Z i VCAE3 Cones riATC I00 - JOB ADDRESS_ z (ji[;� W. Zv��I; V1 CITY/ZIP A1A ')T .&f 7 CROSS STREET L APN Zy 1 3 �t� yS� SPA EL SIZE LAND USE APPLICATION # OWNER ADDRESS S - y S rA i /�C it) CITY�.��TEIZI</�/�?� /L�/ h ,,jaeJ' CONTRACTOR ,✓rtiCt 0f//,AA ��®/.tet PHONE / C 7 - _; a ` /— � CONTRACTOR ADDRESS �Q G� _ CITY/STATE/ZIP /��,yL4 .S %A- e Q ,i4 [ 9'.S 7� d/C-57 WELL DRILLING LICENSE NUMBER ��C� EXPIRATION DATE 7" PERFORATION CONTRACTOR PHONE PERFORAA CONTRACTOR ADDRESS CITY/STATE/ZIP 12 C-57 Well Drilling License Number 714`C l 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 est Hole Detected/Suspected Well Water Contaminant(s)__/lJL%/t! Adjacent property with contamination (Address) Known Soil/Water contaminants at adjacent property-- EXISTING roperty_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 k inches Well Conductor Casing ❑ Yes ❑ No Depth of Conductor Casing It bgs Diameter of Conductor Casing inches 11 Well Casing Diameter_ -2- �t inches Total Depth_ -.fir- It Depth to Water_ 7- ft Depth of Casing Sao — ft bgs DESTRUCTION SPECIFICATION ,/_ Sealing Material from -.-.-C) ft bgs to ft bgs Fi4leriVhdterai V ° i _1CiyLFftbdi 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 ❑ DetonUnq cord and boosters ❑ with projectiles every ft ❑ without projectile Other [ '&-/? 4W4(_6 Se ling Material �Q Neat Cement (94 Ib bag/5-6 gal water) Sand Cement sack mixll gal water Bentonite Pellets Bentonite (20% solids) Manufacturer Spec % solids_ % Name Specs on File Specs Submitted Placement Method ;,/ Pumped Free Fall 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 THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION LAWS. Y8 MINIMUM ;K HOUR ACIVANCE NO REQUIRED FOR INSPECTIONS CON rRACTORS SIGN Ln Application Accepted By _ Destruction Inspection By COMMENTS TITLE //?//V DATE .....,L_L._ i _ RECENE[ _- SEP 14 1`018 SAN JOAQUIN COLIN ENVIRONMENTAL HEALTH DEPARTMEI NT USE ONLY Date ` AreaC/ �r ;/0 Date 1 l Employee ID# PE SC Received Check#/ Amount Codes Info By Cash Remitted Date Permit/ Service Request # Invoice # Well ID# 7 4'� /`% 4T, `4" I � W Pon �7 EHD 43-08 WELL DESTRUCTION PERMIT 4/30/12