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WELL DESTRUCTION PERMIT � J t SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT NON-REFUNDABLE PERMIT \ CALL (209) JOB ADDRESS U CROSS STREET �j OWNER OWNER ADDRESSyJ/f �y T CONTRACTOR CONTRACTOR ADDRESS L/ POC-57 WELL DRILLING LI( PERFORATION CONTRACTOR PERFORATION CONTRACTOR ADDRESS PUBLIC WATER SYSTEM ❑ Yes J2:Go 1868 East Hazelton Avenue - STOCKTON CA 95205 - (209) 468-3420 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED ATE/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 1WReplacement 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 ❑ No Depth of Condu for C sing ft bgs Diameter of Conductor Casing inches Well Casing Diameter_ inches Total Depth 'S'it Depth to Water__it Depth of Casing It bgs DESTRUCTION SPECIFICATION Sealing Material fro, bgs to V ft bgs Filler Material_ from ft bgs to It 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 Seal' Material Neat Cement (94 lb bag/5-6 gal water) Sand Cement sack mix17 gal water Bentonite Pellets Bentonite (20% solids) Manufacturer Spec % solids % Name Specs on File Specs Submitted Pment 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. !8 MI ADVANCE NOTICE REQUIRED FOR INSPECTIONS CONTRACTORS SIGNATURE TITLE,G'C DATE - l I*tP7X ARTMENT USE O LY �] Application Accepted By Date t/ Area / Destruction Inspection By Date Employee ID# COMMENTS TT PE Code SC I fo Received By Check#/ Cash Amount Remitted Date Permit/ Service Request # Invoice # Well ID# �S a6 �Pd6 EHD 43-08 WELL DESTRUCTION PERMIT 4/30/12 ri m Y A v v: