WP0038506 - Laserfiche WebLink

Home Browse Search

T N WELL DESTRUCTION PERMIT PUBLIC WATER SYSTEM ❑ Yes ❑ No SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 600 E MAIN STREET - STOCKTON CA 95202 - (209) 468-3420 AInIU-P=C11MnAQI F PFDIUIT f Al I Ignm Qr%'t-7AQ7 GnD InICDF:rT1n?dQ EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS �' 41 CITY/ZIP ,�) CROSS STREET e f-J� ,s APN L��G �'i"U i�� D 4) PARCEL SIZE LAND USE APPLICATION # OWNERS �� l'! /�f± . �i c� PHONE OWNER ADDRESS L ec k i Ct , J ✓ CITY/STATE/)ZIP Al e+{77-� CONTRACTOR Q j II ( r ih( M PHONE 5 L,7 � L/ CONTRACTOR ADDRESS �� rJ /i-11 { CITY/STATE/ZIP�V ti�('M1 C-57 WELL DRILLING LICENSE NUMBER bl;51'✓Ca2Z EXPIRATION DATE PERRFORATION 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 ,�ogleey. Detected/Suspected Well Water Contaminant(s) Adjacent property with contamination (Address) sy'° Known Soil/Water contaminants at adjacent property e ��p� EXISTING WELL CONSTRUCTION DETAILS Open Bottom ❑ Gravel Pack ❑ Uncased 116If�CrJOQ Well Log copy attached ❑ Yes No Grout Seal ❑ No ❑ Yes ft below ground surface (bgs) Hq"AUN7}hches Well Conductor Casing ❑ Yes No Depth of Conductor Casing ft bgs Diameter of Conductor Ca5i° -_inches inches , Well Casing Diameter_ inches Total Depth �� ft Depth to Water �� ft Depth of Casing J'ft bgs DESTRUCTION SPECIFICATION O 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 ft 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 lb bag/5-6 gal water) Sand Cement sack mix/7 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. MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS CONTRACTORS SIGNATURE TITLE D^ A - T DATE 7- 2— I / DFS ARTMENT USE ON Y Application Accepted By Date Area �ff '0 Destruction Inspection By Date Employee ID# COMMENTS Ir. s S PE SC Received Chec Amount Date Permit/ Invoice # Well ID# Codes Infn By ash JlRemitted Service Request # O EHD 43-08 10/5/07 WELL DESTRUCTION PERMIT