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WELL DESTRUCTION PERMIT 2 (J� f zAL3T .EP �y0 PUBLIC WATER SYSTEM El Yes [:1 No SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPT /o -' 1868 East Hazelton Avenue-STOCKTON CA 95205-6232 -(209)468-3420 NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED 'r. JOB ADDRESSCITY/ZIP 19 • .'. J CROSS STREET APN 0 O PARCEL'04SIZE 1 AND USE APPLICATION# - OWNER '.I tox.'ore I/,,r � PHONE d t n '7'+ OWNER ADDRES/^S��w 11 /T T CITYISTATE21PO//K p(/(GL"Kl.L .66 SZ i CONTRACTOR Vi/ a I' R /'C/•� •/r o.Toe PHONE �1 � �f d q 31-on � /� CONTRACTOR ADDRESS • /�•1/ M L, CITY/STATE21P �/c (�'C `/Clj. I J -off/ C-57 WELL DRILLING /'LICENSE NUMBER 7 7 .Z� � EXPIRATION DATE S-�f -/ ` PERFORATION CONTRACTOR C oif CG7 PHONE S3 0- 16 6 6 /7 h PERFORATION CONTRACTOR ADDRESS .D. ©� �J D CITY/STATE/ZIP 0'--C-57 Well Drilling License Number Y3 Y 2/j? Em�X°Ira�n Date s.�/•/ Bureau of Alcohol,Tobacco and Firearms-Users of High Explosives License Number il-J/J-&-07�"xpiratio�17ate /2 L/ .290 CHP Hazardous Material Transportation for Explosives License Number /3 7/O!7 Expiration Date 2-- San 'San Joaquin County Sheriff-Coroner Explosives Application and Permit License NumberO 2 Expiration Date 6 - California Occupational Safety Health-Blaster License Number C( Expiration Date/2•?9-/ REASON FOR DESTRUCTION ❑ Dry ❑ Replacement Well 09�Caved In ❑ Pit Well IRfactive ❑ 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 B"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 Conductor Casing ft bgs Diameter of Conductor Casing inches Well Casing Diameter 16 inches Total Depth ft Depth to Water ft Depth of Casing 4a ft bgs DESTRUCTION SPECIFICATION Sealing Material from 0 (0 ft bgs to 49 ft bgs Filler Material from ft bgs to ft bgs Well casing to be perforated by one of the following methods: from ft bgs tom ft bgs ❑ Mills Knife Number of cuts every ft and/or 27 D J Explosives❑ Detonating cord ❑ with projectiles every��ft ❑ without projectile��Af-�i• G./�� �n//� q Deton ting ord and boosters ❑ w h projectiles every ..�/�� ft ❑ without projectile / ❑ Otherl�ktc�A7��.�chAPRrs �ms:,►e Sttoh/1/Pwr000 Itl�►RA/itt/'gent P9 Sealing Material Neat Cement(94 Ib b g/5-6 gal ater) Sand Cement D�,�sack mix/7 gal water entonite Pellets Bentonite(20%solids) Manufacturer Spec%solids % Name Specs on File Specs Submitted Placement Method // ✓Pumped Free FaIL— Other Seal Completion 1J4-omplete with Mushroom Cap 6 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 TUF CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION LA MIU UR ADVANCE NOTICE REQUIRED FOR INSPEC IONS CONTRACTORS SIGNATURE Q l�s 0 TITLE j—DATE 7- ry PAYE ENT IS v RECEIVED a AUG 0 1 2018 M JOAQUIN COUNTYENVIRONMENTAL HEALTH DEPARTMENT, /\0 PA MENT USE ONLY Application Accepted By Date Area Destruction Inspection ByDate Employee ID# COMMENT A0WV r1—Z: PE Sc Received Check#/ Amount Permit/ odes Info By Cash emitted Date Service Request# Invoice# Well ID# T2z1—a2 6Cf V1 In W 0 0-3p&a EHD 43-08 WELL DESTRUCTION PERMIT revised 4/14/18