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WELL DESTRUCTION PERMIT PUBLIC WATER SYSTEM ❑Yes ❑No SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPT 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 JOB ADDRESS t CITYZP i �7 CROSS STREET L-C'y C` S�.V(- R b• APN _ 0 PARCEL SIZE LAND USE APPLICATION# e OWNER Ov-'k 11 �!I C f' ,t PHONE n OWNER ADDRESS 1 2S ` e. C 1'd6 c"(A lC�. l\Q CITY/STATE�/7ZIP�A( x r'C�qc :C A S��J b CONTRACTOR Yl PHONE G -977q CONTRACTOR ADDRESS P-C, . t`X .4 : ^ 7 y CITYISTATE/ZIP ��jl�I C'L\ S t7 X C-57 WELL DRILLING LICENSE NUMBER . SIC (�S 3 O EXPIRATION DATE 7111 O 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 fiq 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 X Open Bottom ❑ Gravel Pack ❑ Uncased ❑ Other Well Log copy attached ❑ Yes . No Grout Seal )( No ❑ Yes It 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 Dlameter� —inches Total Depth 4�", ft Depth to Water y(} ft Depth of Casing�It bgs DESTRUCTION SPECIFICATION Cc o(r r-FC Sealing Material from j ft bgs to_ ft bgs Filler Material I •3 S a I< from s _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 X Pumped Free Fall Other Seal Completion Complete with Mushroom Cap 5 it 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 48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS .�/�J a2 � z ff-C S-,&V)t CONTRACTORS SIGNATURE / � / / � TITLE 'I CATE 3 Cr 7D r D mac`\ V) J „S n 9 J 0 %� .V e _ vi cod AQTMENT USE ON Application Accepted By Date l Area Destruction Inspection By DateEmployee ID# COMMENTS PAYMENT RECEIVED QQ PE SC Received Check#/ Amount Permit/ �j_(� O 3 200 Codes Info Remitted Date Service Re uest# Invoice# Well ID# !E–C I D� So JOAQUIN COUNTY ENVIRONMENTAL EHD 43-08 WELL DESTRUCTION PERMIT HMTH DEPARTMENT revised 4/14/18