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WELL DESTRUCTION PERMIT 1 PUBLIC WATER SYSTEM ❑Yes ❑No SAN JOAQUIN 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 e JOB ADDRESS 9 '12al RU i2o 14w CITY/ZIP grea/0-1 11532 m t� Y CROSS STREET ~�Y APN Z-2-Q y S0- VU PARCEL SIZE `Q' LAND USE APPLICATION# OWNER � ' V IKOr1' IIZlVl-G PHONE Z�) 163-V�► l I n OWNER ADDRESS 2 LCIVV't M or. CITY/STAT[E//ZZIIP —setv,Le,4X- 1no, C'I CONTRACTOR dl-S-6 r PHONE .J G��' 1 Q� CONTRACTOR ADDRESS— 1 1!9Y-S • (�L CITY/STATE/ZIP /"A od-e-sTJ G i Cot ot iS 3 s? X C-57 WELL DRILLING LICENSE NUMBER b6A6ZZ EXPIRATION DATE Q-36-14 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 ExpirA _ ❑ California Occupational Safety Health-Blaster License Number Exp REASON FOR DESTRUCTION Dry ❑ Replacement Well ❑ Caved In ❑ Pit Well ❑ Inactive , ❑ Te Detected/Suspected Well Water Contaminant(s) ry Adjacent property with contamination(Address) SAN 9 Known Soil/Water contaminants at adjacent property FNVU//y EXISTING WELL CONSTRUCTION DETAILS Open Bottom ❑ Gravel Pack ❑ Encased ❑ Other_ _ Well Log copy attached ❑ YesNo Grout Seal ❑ No ❑ Yes_ ft 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_ _inches Total Depth�V It Depth to Water_q49 -ft Depth of Casing _It bgs DESTRUCTION SPECIFICATION Sealing Material from _ZT' tt bgs to It bgs Filler Material from ft bgs to_.. _ft bgs Well casing to be perforated by one of the following methods: _ _from It bgs to It bgs ❑ Mills Knife --- Number of cuts every_______.____ft and/or_ ❑ Explosives ❑ Detonating cord ❑ with projectiles every It ❑ without projectile ❑ Detonating cord and boosters ❑ with projectiles every ft ❑ without projectile ❑ Other Sealing Material Neat Cement(94 lb bag15-6 gal water) Sand Cement sack mix/-/gal water Bentonite Pellets X 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 _ 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. UM 34H OUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS CONTRACTORS SIGNATURE TITLE �f Ili^ DATE ....... _._ } qq._ i f...._. _ .. - ......................... _.............. _ -- - - - ..... ! _. .............. I �I .._.........._............ i __.._ _.._... ..... __. T _ I „ I I I _._. ....._.i..... ..-1'- - 1 � f % D ARTMENT USE ONLY / Application Accepted By Date �� 3 6 Area cam' Destruction Inspection By �� Date Zh0`1 Employee ID# c COMMENTS C ) E'1'Trl Yl Exp S r U� S C Finn S v PE SC Received hecl Amount Date Permit/ Invoice# Well ID# Codes Info By, Remitted Service Request# EHD 43-08 WELL DESTRUCTION PERMIT 4/30/12