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WELL DESTRUCTION PERMIT <br /> PUBLIC WATER SYSTEM ❑Yes-�rNo <br /> ' SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPT 1868 East Hazelton Avenue-STOCKTON CA 95205-6232-(209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> t n <br /> JOB ADDRESS Y CITY/ZIp J)t�' L:. DSI �0 <br /> CROSS STREET A APN 7 7 ;3 6CL� 74ARCEL SIZE +`1 LAND USE APPLICATION# o <br /> �`1 N <br /> OWNER G� C) PHONE 1 10 _ " <br /> OWNER ADDRESS CITY/STATE/ZIP w 6 1� <br /> CONTRACTOR , PHONE J­L <br /> CONTRACTOR ADDRESS r O M0 CITY/STATE21P r 14D �( <br /> C-57 WELL DRILLING LICENSE NUMBER y q` SIC EXPIRATION DATE —13L <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 ❑ Dry ❑ Replacement Wel ❑ Caved In C] Pit Well Inactive El Test Hole <br /> Detected/Suspected Well Water Contaminant(s) P4 iQ <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 Li Yes R below ground surface(bgs) Hole Diameter inches <br /> Well Conductor Casing❑ Yes ❑ No Depth of Conductor Casing ft bgs Diameter of Conductor Casing_inches <br /> Well Casing Diameter If inches Total Depth /fl o ft Depth to Water JS ft Depth of Casing ft bgs <br /> DESTRUCTION SPECIFICATION n <br /> Sealing Material from Oft bgs to 0 0 ft bgs Filler Material !J 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 /> ❑ Explosives❑ Detonating cord ❑ with projectiles every ft ❑ without projectile <br /> ❑ Detonating cord and boosters ❑ with projectiles every ft ❑ without projectile <br /> ❑ Other <br /> Seal' g Material Neat Cement(94 lb bag/5-6 gal water) Sand Cement sack mix/7 gal water Bentonite Pellets <br /> V Bentonite(20%solids) Manufacturer Spec%solids X6% Name Specs on File Specs Submitted <br /> Placement Method Pumped Y j/fliIN (Free Fall Other <br /> Seal Completion Complete with Mushroom Cap It 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 /> MI 48 HOA ADVA E NOTICE REQUIRED FOR INS P CTIONS <br /> CONTRACTORS SIGNATURE TITLE DATE <br /> ..,, .. e AYMENT <br /> ,.....__...._......__.........c.......�_ L... _. r _ _ <br /> _ RECEIVED <br /> ; <br /> APF 26 2019 <br /> Or Ji Z <br /> yJL11 Q av SAN OAQUIN COUNTY <br /> Y \1J oqf� ( E VIRONMENTAL <br /> (�[ HEA TH DEPARTMENT <br /> 6 . STry <br /> p TMENT USE ONL �J <br /> Application Accepted By V Date Area <br /> Destruction Inspection Date Employee ID# <br /> COMMENTS <br /> PE SC Received hec Amount Date Permit/ Invoice# Well ID# <br /> Code Ino B ash Remitted Service Re uest# <br /> qjiL <br /> EHD 43-08 WELL DESTRUCTION PERMIT <br /> revised 4/14118 <br />