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WELL DESTRUCTION PERMIT I/ ✓ � PUBLIC WATER SYSTEM ❑ Yes [71To SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 East Hazelton Avenue - STOCKTON CA 95205 - (209) 468-3420 NON-REFUNDABLE PERMIT CAI I fgnm 953-7AC17 FnM 1nlco9:1TInKIQ 1=Y9)IRF4Z 1 VCAD Gonne nATC ICVl M �, / / JOB ADDRES�'(j!�r W / [✓S %/� A (/Fi ---- - -- -- --------- ------ CITY/ZIP ( ' C CROSS �'L APN2_Y9/0J_3 PARCEL SIZE LAND USE APPLICATION # �STREET ` r^ y �/r / P✓� J� i / -/ ONE / - OWNER ADDRE (� L� / �f ('10 C '/�> Y/STATERIP /iC !7 /✓� 4 CONTRACTOR //f+ PHONE 0' -31,/ - CONTRALTO DDRESS_Q7 ./C." CITY/STATERIP/V/Gj ` C-57 WELL DRILLING LICENSE NUMBER__// O f EXPIRATION DATE PERFORATION CONTRACTOR PHONE PERFORATION CONTRACTOR ADDRESS CITY/STATE/ZIP Q/(l57 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 Hole Detected/Suspected Well Water Contaminant(s) f✓/ T rt/ – Z 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 i!? "i inches Well Conductor Casing ❑ Yes ❑ No Depth of Conductor Casing ft bgs Diameter of Conductor Casing inches Well Casing Diameter_ inches Total Depth _ It Depth to Water__ ft Depth of Casing 30 _ It bgs DESTRUCTION SPECIFICATION Sealing Material from _ �s to It bgs � 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 to ❑ I t) cord an bposters ❑ with projectiles every It ❑ without projectile (a Other C Sealin aterial Neat Cement (94 Ib bag/5-6 gal water) Sand Cement sack miu%/ gal water Bentonite Pellets entonite (20% solidsj &" anufacturer Spec % solids—_—% Name Specs on File Specs Submitted Placement Method Pumped Free Fall 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 THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION LAWS. 110 7V MINIMt), M HOU DVANCE TICE REQUIRED FOR INSPECTIONS CONTRACTORS SIGNATURE , TITLE DATE ��/�C. DATE ARTMENT Application Accepted By Destruction Inspection By COMMENTS USE ONLY Date Date q 1 C/ a 2018 H EF/VV RONM COUNTY LTH DFoAFNTAL - Area m 00 Employee ID# PE Codes SC Received Info By Check#/ Cash Amount Remitted Date Permit/ Service Request # Invoice # Well ID# 3 7 10 ItA q 9 4-o 1 / S �l r ►g W P EHD 43-08 WELL DESTRUCTION PERMIT 4/30/12