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WELL DESTRUCTION PERMIT <br /> PUBLIC WATER SYSTEM ❑Yes ❑No <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 600 E MAIN STREET-STOCKTON CA 95202 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YE R FROM DATE ISSUED <br /> JOB ADDRESS I t Of CITY/ZIP CIL ✓`� m <br /> CROSS STREET — A, Y}• 'rL.1 APN PARCEL SIZ LAND USE APPLICATION# <br /> ^� o <br /> OWNER !�`—�� (�Cst)/(. PHONE L— O.-F-) ry' <br /> rn <br /> OWNER ADDRESS CITY/STATE/ZIP <br /> n (/ 7 <br /> CONTRACTOR `} �V /LG l h• PHONE 2) C <br /> CONTRACTOR ADDRESS CITY/STATE/ZIP <br /> / C-57 WELL DRILLING LICENSE NUMBER n EXPIRATION DATE �� Z I <br /> PERFORATION CONTRACTOR PHONE <br /> PERFORATION CONTRACTOR ADDRESS CITY/STATE/ZIP <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 Z 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 Soil/Water contaminants at adjacent property <br /> EXISTING WELL CONSTRUCTION DETAILS ❑ Open Bottom ❑ Gravel Pack ❑ Uncased ❑ Other <br /> Well Log copy attached ❑ Yes & No Grout Seal ❑ No ❑ Yes ft below ground surface(bgs) Hole Diameter inches <br /> Well Conductor Casing 13 Yes �'No Depth of Conductor Casing ft bgs Diameter of Conductor Casing inches <br /> Well Casing Diameter < I inches Total Depth-94 ft Depth to Water eZ ft Depth of Casing ft bgs <br /> DESTRUCTION SPECIFICATION <br /> Sealing Material from ')_0 ft bgs to ft bgs Filler Material /�11^/I✓( l from 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 /> ElExplosives ❑ 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(94 Ib bag/5-6 gal water) Sand Cement sack mix17 gal water < Bentonite Pellets <br /> Bentonite(20%solids) Manufacturer Spec%solids % Name Specs on File - Specs Submitted <br /> Placement Method ❑ Pumped Ile Free Fall Other <br /> Seal Completion ❑ Complete with Mushroom Cap 4 ft bgs ❑ Complete to Existing Surface Pad <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 CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> Mit <br /> ,AIMUM Z4 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br /> CONTRACTORS SIGNATURE TITLE 6 .)/1� DATE <br /> r <br /> r <br /> PAYMENT <br /> — — 'EIVED <br /> .Jt/! 12 2019 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> h—'1 /'Y� -- —� ±±+ i -- —r <br /> _JD.EPARTM ENT USE ON L <br /> Application Accepted By Date 7 al C1Area ��L� <br /> Destruction Inspection By Date T n <br /> / Employee 1 #_ <br /> 01 <br /> COMMENTS i Z r <br /> PE SC Received Check#/ Amount Date Permit/ Invoice# Well ID# <br /> Codes Info Cash Remitted Service Request# <br /> EHD 43-08 WELL DESTRUCTION PERMIT <br /> 10/5/07 <br />