Laserfiche WebLink
WELL DESTRUCTION PERMIT <br />PUBLIC WATER SYSTEM ❑ Yes OL -No <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 East Hazelton Avenue - STOCKTON CA 95205 - (209) 468-3420 <br />NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS "7 7 <br />. l C. <br />CITY/ZIP 15%� <br />`/I <br />CROSS STREET ���%/�/ APN <br />PARCEL SIZE LAND USE APPLICATION # <br />`�L <br />/ <br />OWNER / i-+ <br />G <br />-(' NE <br />OWNER ADDRESS AS— <br />CITY/STATE/ZIP <br />CONTRACTOR/ PHONE',I—;�?/LS <br />CONTRACTOR ADDRESS ZL' <br />CITY/STATE/ZIP <br />TC-57 WELL DRILLING LICENSE NUMBER Q �� <br />EXPIRATION DATE <br />PERFORATION CONTRACTOR <br />PHONE <br />PERFORATION CONTRACTOR ADDRESS <br />CITY/STATE/ZIP <br />❑ 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 Expi <br />❑ San Joaquin County Sheriff -Coroner Explosives Application and Permit <br />License Number Exp Val[ �❑ <br />California Occupational Safety Health - Blaster <br />License Number Expira <br />REASON FOR DESTRUCTION WDry [I Replacement Well E] Caved In El Pit Well ❑ Inactiv C' E21e ole <br />Detected/Suspected Well W5ter Contaminant(s) <br />ZU18 <br />Adjacent property with contamination (Address) <br />JOAQUiN <br />Known Soil/Water contaminants at adjacent property <br />NEZ Vitt VM�1 <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 ❑ Yes ❑ No Depth of Conductor Casing <br />ft bgs Diameter of Conductor Casing inches <br />Well Casing Diameter_��inches Total Depth e __ ft Depth to Water It Depth of Casing It bgs <br />DESTRUCTION SPECIFICATION <br />Sealing Material from ___ ft bgs to ft bgs Filler Material <br />from It bgs to ft bgs <br />Well casing to be perforated by one of the following methods: <br />from ft bgs to It bgs <br />❑ Mills Knife Number of cuts every It and/or <br />— - <br />❑ Explosives ❑ Detonating cord ❑ with projectiles every <br />ft ec le <br />❑ Detonating cord and boosters ❑ with projectiles every <br />❑ with t prole:I <br />❑ Other <br />(l <br />Sealing Material Neat Cement (94 lb bag/5-6 gal water) -� Sand Cement <br />sack mix/7 gal water a nite Pellets <br />Bentonite (20% solids) Manufacturer Spec so' s _% Name <br />1 Sp cs ubmitted <br />Placement Method rl Pumped :�% F e Fall n <br />Other <br />Seal Completion Complete with Mushroom Cap bgs fL 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. <br />Yg �I <br />M H VANCE NOTICE REQUIRED FO/R� INSPECTIONS <br />CONTRACTORS SIGNATURE TITLE //1�C DATE <br />_71 <br />Application Accepted By <br />Destruction Inspection By <br />COMMENTS 1412--1 <br />- -__ <br />;L� _ , _ <br />DEPARTMENT USE ONLY <br />Date � Area <br />Date Employee ID 4 <br />��V e1n�� - aM sled <br />&"-:s ��t`-zs ` W s lay 4,e_IU-rt s ems► �a <br />111A rmfin,4­1. 1nr"-O6 -11) Msfam a8 3 w► cP, f--GKY14des <br />PE <br />SC <br />Received <br />Amount <br />Permit/ <br />Codes <br />Info <br />B <br />Cash Remitted <br />Date <br />Service Request # <br />Invoice # <br />Well III <br />Siu <br />1 <br />P 01� 612-_- <br />, <br />-- <br />EHD 43-08 <br />4/30/12 <br />Ca4' �g3777-7J WELL DESTRUCTION PERMIT <br />