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WELL DESTRUCTION PERMIT PUBLIC WATER SYSTEM ❑Yes ❑No SAN JOAOUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 East Hazelton Avenue-STOCKTON CA 95205 - (209)468-3420 NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS �/ V CRYIZIP / 7 C./, l-41 m CROSS STREET APN PARCEL SIZED RAND USE APPLICATION# OWNER ( S�i L IL( PHONE OWNER ADDRESS co'r(0t'�'? C�— � TATE/ZIP CONTRACTOR �/ / PHONE CONTRACTOR ADDRESS ' 0k) I' t 950 CITY/STATE/ZIP l f/`n rq Cl�� Cl/I I C-57 WELL DRILLING LICENSE NUMBER D-s -.7 O EXPIRATION DATE PERFORATION CONTRACTOR PHONE PERFORATION CONTRACTOR ADDRESS CITY/STATE/ZIP A 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 )0 Caved In ❑ Pit Well ❑ Inactive ❑ Test Hole Detected/Suspected Well Water Contaminants) Adjacent property with contamination(Address) Known Soil/Water contaminants at adjacent property_ EXISTING WELL CONSTRUCTION DETAILS ❑ Open Bottom ❑ Gravel Pack ❑ Uncased ❑ Other Well Log copy attached ❑ YesNo 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 Diameter � f —inches Total Depth Depth to Water It Depth of Casing _ ft bgs DESTRUCTION SPECIFICATIO �A ( b tol!9'If Sealing Material from —40 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 It bgs ❑ Mills Knife Number of cuts every __.__,_ft and/or ❑ Explosives ❑ Detonating cord ❑ with projectiles every ft ❑ without projectile El Other ❑ Detonating cord arid boosters ❑ with projectiles every ft ❑ without projectile 'f►"fl (V �L.� � Sealing Material Neat Cement(94 Ib bag/5-6 gal water) Sand Cement sack mix/7 gal water i*\ Bentonite Pellets Bentonite(20%solids) Manufacturer Spec%solids__ _% Name Specs on File Specs Submitted Placement Method Pumped Free Fall ( Other Seal Completion Complete with Mushroom Cap �J 'f 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. IJD YS MIN UM 34 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS CONTRACTORS SIGNATURE TITLE CJ ` DATE �l -S I (� . ' S I n r ............................................... ........ I � I I ................................................ I ---------..............301 I E —• -_.....— __._ ._. _ .._. _. _ _.__... ....... - _— __ ....... -- .. — - — —_ — _� .. _ - P -�-- _4RECE ANT _.. __ _. IVE® -;- ........ -.... ..........._...-. __ _._._.__.;_�_._ ------- -_ _ _.. _..... AUG Z I 1 2018 _ 4N JOA _ L�.. __. -:__. _. .... T..._.. ._ _...... ._ ._.. .- HamQUINCOU n, . ElmRONMENT EPAR7 _ MENT FF 4 .. _.. _.._.__ .. _ _.. . RTMENT USE O L �f Application Accepted ByCT 01 Date /� J� Area ` Destruction Inspection By L v Date �1 f/(/1 25 Area ID# COMMENTS PE SC Received C Clheckffl Amount Permit/ o e fo B s milted Date Service Re uest# Invoice# Well ID# �� Q0, EHD 43-08 WELL DESTRUCTION PERMIT 4/30/12