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r"N �/ ' WELL DESTRUCTION PERMIT i' PUBLIC WATER SYSTEM ❑Yes jao SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 East Hazelton Avenue-STOCKTON CA 95205 - (209))4468-3420 NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS �� IX-37CITY/ZIPf !i(/� D ,— CROSS STREET �� V v P RCEL SIZE L V LAND USE APPLICATION# C j] Ae T OWNER .-� '�+� P ONE OWNER ADDRESS <�0e,-A-Je- AZ AZi� CCITY/STATE/ZZIIP� : CONTRACTOR � ^l ,Z PHONE100, CONTRACTOR ADDRESS 24,ge CITY/STATE/ZIP C-57 WELL DRILLING LICENSE NUMBER .-Z 1 fC A EXPIRATION DATE Z 119 PERFORATION 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 ❑ Test Hole Detected/Suspected Well Water Contaminant(s) �„ T Adjacent property with contamination (Address) Known Soil/Water contaminants at adjacent property_ EXISTING WELL CONSTRUCTION DETAILS ❑ Open Bottorn ❑ Gravel Pack ❑ Uncased ❑S,O her Well Log copy attached ❑ Yes ❑ No Grout Seal ❑ No ❑ Yes It below ground surface(bgs) HoIAAn�tO _ inches Well Conductor Casing ❑ Yes ❑ No Depth of Conductor gasing --_ _ ft bgs Diameter of CorAt� �l*inches Well Casing Diameter inches Total Depth _,`— ft Depth to Water ft Depth of CasiinggRT.Fid It bgs DESTRUCTION SPECIFICATION/ Sealing Material from fD ft bgs to U - 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 FI Pumped ,V Free Fall Other Seal Completion Complete with Mushroom Cap It bgs 'IV 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. LJAO -Ip M 1 UR ADVANCE NOTICE REQUIRED FOR INSPECTIONS CONTRACTORS SIGNATURE PTITLE I�C/� DATE j ..._...._. . � w _ i € J\ I _.. v i 3 .«...._. __._..___€._......................... ..... ' ... ... , i P A R T M E N T U S E O N L Y ) Application Accepted By2� Date 'JS r'� Area w '� Destruction Inspection By Aej'w� t1 _ Date l Employee ID# COMMENTS b ,C- W 61 4e r PE Sc Received ck#/ Amount ate Permit/ Invoice# Well ID# Codes Info B Cash R mitted Service Request# y3 ; 1 l 'lS EHD 43-08 WELL DESTRUCTION PERMIT 4/30/12