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WELL DESTRUCTION PERMIT . I PUBLIC WATER SYSTEM ❑ Yes ❑ No SAN JOAOUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 East Hazelton Avenue - STOCKTON CA 95205 - (209) 468-3420 N0N-RFFI1NnAR1 F PERMIT CAI 1 on9l 4si-7897 FnR INS3PFrtTIr1PIC FXPIRFC 1 VFAR GonM nATC ICQIICn JOBADDRESS I'Z%-j,(o Frc^4 i y&q? CITY/ZIP _MAV ,rtp , CROSS STREET APN Z (i1c,' 116 120 PARCEL SIZE4.b4Q_ANDD USE APPLICATION # OWNER CA V le, S .y�.1 oyek r- PHONE S) U ` 50-t/h16 j� OWNER ADDRESS Z1 9 '3 rape 4 rA AD /} U CITY/STATE21P_,��i, ^� ` eR , CA 7 n C J 3 6 CONTRACTOR I f 1 'k _ PHONE S2-21— CONTRACTOR ADDRESS q rS CITY/STATE/ZIP_ �7C {p c i J �j Al C-57 WELL DRILLING LICENSE NUMBER EXPIRATION DATE Ld 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) Adjacent property with contamination (Address) Known Soil/Water contaminants at adjacent property EXISTING WELL CONSTRUCTION DETAILS Y 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 _ It bgs / Diameter of Conductor Casing inches Well Casing Diameter _L_ inches Total Depth -76 ft Depth to Water? Q ft Depth of Casing _ It bgs DESTRUCTION SPECIFICATION Sealing Material from _Oft bgs to _ d 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__ It 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 e Ing Material 1 Neat Cement (94 Ib bag/5-6 gal water) Sand Cement sack mixl7 gal water Bentonite Pellets Bentonite (2 °° solids) Manufacturer Spec % solids % Name _ Specs on File i Specs Submitted Placement Method Pumped Free Fall Other Seal Completion 1 Complete with Mushroom Cap �r 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. YS MINIMUM ,X HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS CONTRACTORS SIGNATURE �� TITLE D ri- 1 Cr DATE�- re V4c k! Y'1� i t �..� t I Application Accepted By Destruction Inspection By COMMENTS i..... ........ ........ ., I _ I S w. { �D PARTMENT USE ONL / Date b Area Date Employee ID# PE Cod Sc Info Received he Cash Amount Femitted Date Permit/ Service Request # Invoice # Well ID# EHD 43-08 4/30/12 WELL DESTRUCTION PERMIT