FIELD DOCUMENTS - Laserfiche WebLink

Home Browse Search

WELL DESTRUCTION PERMIT NATERSYSTEM❑Yes No SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE 3YO FL-STOCKTON CA 95202-(209)468-3420 NON-REFUNDABLE PERMIT CALL(2091953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED 11 JOB ADDRESS om�.,, a Q CrrY/L1P y CROSS STREET SCA (V,-e. / N l I 00�V PARCEL SIZE LLAND USE APPLICATION# O OWNER PHONE OWNER ADDRESS 2-0 W ! A CITY/STAT/4E/ZCo1P S 0,V�../ q CONTRACTOR CL'.AY ` ExovN n L PHONE CONTRACTOR ADDRESS Z3 ^ W (.A WG� _//C\,. CrrY/STATE/LIP C-57 WELL DRILLING LICENSE NUMBER S �✓ 6 EXPIRATION DATE PERFORATION CONTRACTOR PHONE PERFORATION CONTRACTOR ADDRESS CITY/STATE/LIP ❑ C-57 Well Drilling License Number Expiration Date / ❑ Bureau of Alcohol,Tobacco and Firearms-Users of High Explosives License Number Expiration Date 't"i^• ❑ CHP Hazardous Material Transportation for Explosives License Number Expiration Date V , ❑ 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) V d G 15 Adjacent property With contamination(Address) - Known Sal/Water contaminants at adjacent property `- EXISTING WELL CONSTRUCTION DETAILS ❑ Open Bottom ❑ Gravel Pack ❑ Unaged ❑ Other _ p Welt Log copy attached ❑ Yes ❑ No Grout Seal ❑ No ❑ Yes____ _ft 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 iv-inches Total Depth "! Depth to Water_ft ft Dft Depth of Casing fl bgs DESTRUCTION SPECIFICATION }}yy n Sealing Material from V ft bgs to '1D 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 ft bgs ❑ Mills Knife Number of cuts every ft and/or- 13 nd/or❑ Explosives ❑ Detonating cord ❑ with projectiles everyft ❑ without projectile ❑ Detonating cord and boosters ❑ with projectiles every___ ft ❑ without projectile ❑ Other Sealing Material U$ J(Wnt(9416 bag/S-6 gal water) A Sand Cement .wck mix/7 gal water ❑ Bentonite Pellets ❑ Bentonite(200%�solids) ❑ Manufacturer Spec%solids-- % Name _ _____ ❑ Specs on File ❑ Specs Submitted Placement Method>(,Pumped ❑ Free Fall ❑ Other Seal Completion ❑ Complete with Mushroom Cap ft bgs ❑ Complete to Existing Surface Pad 1 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 CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT 1 AM IN COMPLIANCE WITH ALL WORKERS COMPENSA 019 LAW . MINI UM 24 HOUR ADVANC N ` I 'E REQUIRED FOR INSPECTIONS CONTRACTORS SIGNATURE TITLE l//ti DATE DEPARTMENT USE ONL > PAYMENT Application Accepted By (/�C�YwI/Lrti'IA/� Date Tea Z't GI Destruction Inspection By �ijQ,n_[�/•27�_ __ Date S Employee ID# RECEIVED _ COMMENTS AN JOAQUIN COUNTY PE' VIIHONMENTAL Codes Info Received «y ChecldN Remitted �rvke Ret meatPerm / # EALTH DEPARTMENT unt Date Invoice# Well ID# Ettn Ci-tR-0I18 1mrza6 W cn Iks fi—p—