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WELL DESTRUCTION PERMIT f <br />PUBLIC WATER SYSTEW No <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 East Hazelton Avenue - STOCKTON CA 95205 - (209) 468-3420 <br />NON-RFFt1NDARI_F PFRMIT rat I /9nm Qr,3-7RQ7 FnD IBICDVr'TInAIQ GVDIDC(2 1 VLAM C -A r% r Inn 1— <br />JOB ADDRESS 6'r/c 1',) A fJj::�_ <br />CITY/ZIP <br />CROSS STREET / A,) S APN 2 Y 7 <br />PARCEL SIZE LAND USE APPLICATION # <br />G!II /�' PHONE3�U <br />OWNER ADDRESS /V- ® L lvS S G / I ATER�t1 p /1– <br />LCONTRACTOR <br />CONTRACTOR/�j !� �Cc// G <br />--An d- <br />PHONE �V 7 �3� 4--And- <br />CONTRACTOR <br />CONTRACTOR ADDRESS ` �� 33�? <br />[� c r, <br />CITY/STATERIP A /y �,lS f j_ C % �% <br />/� <br />f- C-57 WELL DRILLING LICENSE NUMBER Z.14 o 7 �/ <br />EXPIRATION DATE 7 <br />PERFORATION CONTRACTOR <br />PHONE <br />PERFORATION CONTRACTOR ADDRESS <br />CITY/STATE/ZIP <br />91—C'57 Well Drilling <br />License Number `% Expiration Date <br />❑ Bureau of Alcohol, Tobacco and Firearms - Users of High Explosives <br />License Number Expiration Date <br />❑ CHP Hazardous Material Transportation for Explosives <br />License Number Expiration Date <br />❑ San Joaquin County Sheriff -Coroner Explosives Application and Permit <br />License Number Expiration Date <br />❑ California Occupational Safety Health - Blaster <br />License Number Expiration Date <br />REASON FOR DESTRUCTION ❑ Dry ❑ Replacement Well ❑ Caved In ❑ Pit Well ❑ Inactive ZITest Hole <br />Detected/Suspected Well Water Contaminant(s) <br />Adjacent property with contamination (Address) <br />Known Soil/Water contaminants at adjacent property <br />EXISTING WELL CONSTRUCTION DETAILS ❑ Open Bottom ❑ Gravel Pack ❑ Uncased ❑ Other <br />Well Log copy attached ❑ Yes ❑ No Grout Seal ❑ No ❑ Yes ____ <br />ft below ground surface (bgs) Hole Diameter inches <br />Well Conductor Casing ❑ fps ❑ No Depth of Conductor Casing <br />ft bgs Diameter of Conductor Casing inches <br />Well Casing Diameter'? -4--_ inches Total Depth _ �_ -ft Depth to Water_ -71 It Depth of Casing `3 It bgs <br />DESTRUCTION SPECIFICATION <br />P <br />,�I <br />Sealing Material from !� It bgs to It bgs Filler M ter�dl_' !mow �GE� r7rom It bgs to 3G' ft bgs <br />Well casing to be perforated by one of the following methods: <br />_from _ It bgs to It bgs <br />❑ Mills Knife Number of cuts every It and/or <br />❑ Explosives ❑ Detonating cord ❑ with projectiles every <br />ft ❑ w;thout projectile <br />❑ Detonating c,ojd and boosters ❑ with projectiles every <br />Other t'ir�%�'/GPA*�Iez <br />ft ❑ without projectile <br />Se ling Material mat Cement (94 Ib bag/5-6 gal water) i Sand Cement <br />sack mix/7 gal water Bentonite Pellets <br />� V Bentonite (20% solids) Manufacturer Spec % solids_ __ _ % Name <br />Specs on File Specs Submitted <br />Placement Method r/ Pumped i Free Fall <br />Other ;' <br />�_ie <br />Seal Completion Complete with Mushroom Cap ft bgs <br />Complete to Existing Surface Pad <br />I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br />JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br />CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br />WORKERS COMPENSATION LAWS. y8 <br />MINIMUM HOUR ANCE TICE REQUIRED FOR INSPECTIONS i <br />CONTRACTORS SIGNATURE CC TITLE _�%� . DATE_ V-13� <br />-- - <br />-He <br />c. <br />Application Accepted By <br />Destruction Inspection By <br />COMMENTS <br />PARTMENT USE ONL <br />Date <br />Date / <br />PAY <br />_ SES 4 X018 <br />SAN/R0 SIN �0� <br />NTH r7EpMFNTA N7Y <br />- TMFNT <br />Ared/ r <br />Employee ID#_ <br />PE SC ReceivedCheck#/ Amount Date <br />Codes Info B Cash Remitted <br />Permit/ <br />Service Request # <br />Invoice # <br />Well ID# <br />37 1-i$4b I _I0 <br />W PG6'5$77 <br />EHD 43-08 WELL DESTRUCTION PERMIT <br />4/30/12 <br />