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WELL DESTRUCTION PERMIT 0 PUBLIC WATER SYSTEM ❑ Yes ❑ No SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 East Hazelton Avenue - STOCKTON CA 95205 - (209) 468-3420 tU(1NI_Rcrllnlneal G Pr-MRAIT C,&I I fgf191 963-7697 FnR INRPFCTInNS EXPIRES 1 YEAR FRt7M DATE ISSUED JOB ADDRESS 7- y3�S ( 1/ii�8Ay. /Z,-1 CITY/ZIP/' C < < . 7 CROSS STREET Ar l Fj�/1 S /ZFl APN,�S/? -C fW ' PARCEL SIZE i b AND USE APPLICATION # OWNER ll&z?�-_>IC% PHONE �T/� � SS 79 OWNER ADDRESS 279113 $ i'i!R/Si11//7 /�� CITY/STATE/ZIP Y� //L ��/ -14- -CONTRACTOR CONTRACTOR PHONE 2Dll 7 Z - Z 7 S- % CONTRACTOR ADDRESS {�G1�' �oo��/� /��`! .Pl� CITY/STATE/ZIP ///411i%elS%/i�js ,/-7 ( C-57 WELL DRILLING LICENSE NUMBER ��1 7076 EXPIRATION DATE 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 �Z 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 §d Open Bottom ❑ Gravel Pack ❑ Uncased ❑ Other Well Log copy attached ❑ Yes ❑ No Grout Seal 81 No ❑ Yes ft below ground surface (bgs) Hole Diameter 6P inches Well Conductor Casing ❑ Yes ❑ No Depth of Conductor Casing _ ft bgs Diameter of Conductor Casing inches Well Casing Diameter __�__ inches Total Depth 41-5_ It Depth to Water_ ft Depth of Casing A21 11 A -WR bgs DESTRUCTION SPECIFICATION Sealing Material from 00 ft bgs to It 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 Sea[' g Material Neat Cement (94 Ib 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 PI c ent Method )I! Pumped Free Fall Other Seal Completion n Complete with Mushroom Cap 3 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. MINI U 4 HOUR ADV NOTICE REQUIRED FOR INSPECTIONS CONTRACTORS SIGNATURE to TITLE<y./�.fr� j DATE E �• . -- - - A L3/e/ 4f'111_1CnVP zoo ........... r U!N COUNT _ J ---MENTAL i DE ARTMENT USE ON Y / Application Accepted By Date Area Destruction Inspection By ALIJ o_ai, AtkwDate j Employee ID# COMMENTSrr� ,Lf 7,c� PE Code SC Inf Receivedec B ash Amount emitted Date Permit/ Service Request # Invoice # Well ID# C7 G-11046 WIiA EHD 43-08 WELL DESTRUCTION PERMIT 4/30/12 7r