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WELL DESTRUCTION PERMIT <br />PUBLIC WATERS(STEM ❑ Yes ❑ No <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPT 1868 East Hazelton Avenue-STOCKTON CA 95205-6232 - (209) 468,420 <br />NON-REFUNDABLE PERMIT C: LL (2019) 953-7597,'C1 iNS�ECTICNS EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS 15863 French Camp Rd _ clT 0PRipon95366 <br />CROSS STREET Murphy Rd APN 2 0 3 - 0 8 0 - 2 3 PARCEL SIZE —.UD USE APPLICATION # <br />owNER Wen Chang Su AA10 NE 209-402-8656 <br />OWNERADDREs4204-- Paquentte CirZ crrr/sTATEiAodesto, CA 95356 <br />CONTRACTOR PurvianceDri7 ers, nc. PHONE 209-887-3554 <br />CONTRACTOR ADDRESS PO Box 64 cI1y/STATE21PLIn�d2en, CA 95236 <br />C57 WELL DRILLING LICENSE NUMBER 317913 EXPIRATION DATE <br />PERFORATION CONTRACTOR PHONE <br />PERFORATION CONTRACTOR ADDRESS CITY/STATEJZIP <br />❑ C-57 Well Drilling License Number Expiration Date <br />Bureau of Alcohol. Tobacco and Firearms - Users of High Explosives License Number Expiration Date <br />CHP Hazardous Material Transportation for Explosives License Number Expiration Date <br />San Joaquin County Sheriff -Coroner Explosives Application and Permit License Number Expiration Date <br />California Occupational Safety Health - Blaster License Number Expiration Date <br />REASON FOR DESTRUCTION X Dry ❑ Replacement Well ❑ Caved In ❑ Pit Well ❑ Inactive ❑ Test Hole <br />Detected / Suspected Well Water Contaminant(s)—�/ <br />Adjacent property with contamination (Address) <br />Known Sol / Water contaminants at adjacent propertyW <br />EnSTING WELL CONSTRUCTION DETAILS )d Open Bottom ❑ Gravel Pack ❑ Uncased ❑ Other <br />Well Log copy attached ❑ Yes )I No Grout Seal ❑ No ❑ AYnes _ft below ground surface (bgs) Hole Dlameter Inches <br />Well Conductor Casing ❑ Yes 30 No Depth of Conductor Casing -=.� <br />/ A— ft bgs Diameter of Conductor Casing Inches <br />Well Casing Dlameter--? _ Inches Total Depth �D _ft Depth to Water -420-f- ft Depth of Casing fl bfls <br />DF_STRDCnON SPECTFir~ATION <br />Sealing Material from l90 ft bgs to D ft bgs Filler Material /i1Xln . from 4(00 ft bgs to ft bgs <br />Well casing to be perforated by one of the following methods: from ft bgs to ft bgs <br />❑ Mills Knife Number of cuts every ft and / or <br />❑ Explosives ❑ Detonating cord ❑ with projectiles every ft ❑ without projectile <br />❑ Detonating cord and boosters ❑ with projectiles every ft ❑ without projectile <br />❑ Other <br />Sealing Material Neat Cement (9416 bag /5.6 gal water) Sand Cement /o. 3 sack mix/ 7 gal water Bentonite P4919ts <br />Bentonite (20% solids) ufacturer Spec % solids_ % Name Specs on File Specs SubmiaM <br />Placement MethodPu a Free Fall OtherH EN <br />Seal Completion Complete with Mushroom Cap ft bgs X Complete to Existing Surface Pad E <br />to 2220, <br />9 <br />fQU <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 CALFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br />WORKERS COMPENSATION LAWS. <br />C�I''Ilf: �,,2,1HO 113VA-iCE N-LOT!CE REQU1,RE0 FO? i'N iSPE-C ilONS <br />CONTRACTORS SIGNA TITLE Secretary DATE 2/22/19 <br />Application Accepted By - <br />DesWction Inspection By <br />COMMENTS <br />EP RTMENT USE ON Y <br />V Date / Area V/'M <br />I <br />Date � Employee IDR <br />PE SC Received Check#/ <br />Amount pate <br />Permltl <br />Invoice# Well ID# <br />Code I fo <br />emitted <br />Service Re uest# <br />fl62 U I <br />EHD 4308 WELL DESTRUCTION PERMIT <br />101907 <br />