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.. - WELL DRUCTION PERMIT PUBLICWATERSYSI'EM es [I NO SAN JOAQUIN CO1JNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE 3N°FL-STOCKTON CA 95202 - (209)468- NON-REFUNDABLE PERMIT CALL(209)953-7697 FOR INSPECTIONS EXPIRES I YEAR FROM DATE ISS r. LE COPY JOB ADDRESS a1[ CITYIZIP q 4 9 CROSS STREET 2— APN &7/-2,50-^�f PARCEL SIZEANO USE APPLICATION# 0 a OWNER PHONE JJ !/y,- (� j OH'NF.RADDRESS CITYISTATEIZIP1�,[; lac CONTRACTOR PIIONF. / y CONTRACTOR ADDRESS CITY/STATEIZIP/ �y 2J Kit 7 i 1P C-57 WELL DRILLING LICENSE NUMBER EXPIRATION DATE /^ PERFORATION CONTRACTOR PHONE PFRFl7 TION CONTRACTOR ADDRESS CITYISTATEIZS5IP IC-57 Well Drilling License Number ,5� 9 � Expiration Date, e' ❑ 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 Safe[ Health-Blaster License Number Expiration Date REASON FOR DESTRUCTION 16 Dry ❑ Replacement Well ❑ Caved In ❑ Pit Well ❑ Inactive ❑ Test Hole Detected!Suspected Well Water Contaminant(s) 1 Adjacent property with contamination (Address) Known Soil I Water coot aminants at adjacent property EXISTING WELL C(NSTRuCT10N DETAILS 11KOPen Bottom ❑ Gravel Pack ❑ Uncased ❑ Other Well Log copy attached fU Yes El No Grout Seal ❑ No ❑ Yes fl below ground surface(bgs) Hole Diameter inches Well Conductor Casing ❑ Yes ❑ No Depth of Conductor Casing A b 5 Diameter of Conductor Casing inches Well Casing Diameter__/_()_inches Total Depth !�3 R Uepth to Water CI- R Depth of Casing f1 bgs DESTRUCTION SPECIFICATION /� Sealing Material from JR bgs io V R bgs Filler Material ' s _from R bgs to fl bgs Well casing to be Perforated by one of the fullo,vine methods: from R bgs to ft bgs ❑ Mills Knife Number of cuts every fl and I or ❑ Explosives ❑ Detonaling cord ❑ with projectiles everyR ❑ without projectile ❑ Detonating cord and boosters ❑ with projectiles every R ❑ without projectile ❑ Other Sealing Material ❑ Neat Cement(94 1h hag/5-6 gal water) and Cement •rack mix 17 gal water cntoaite Pellets ❑ Bentonite(20%solids) ❑ ufacturer Spec I/.solids % Name ❑ Specs on File ❑ Specs Submitted Placement Method❑ Pumped Free Fall ❑ Other Seal Completion Or Complete with Mushroom Cap R 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 15 S' CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL 1 WORKERS COMPENSATION LAWS. MI UM 24 HOUR ANCE NOTICE REQUIRED FO INSPECTIONS CONTRACTORS SIGNATURE ` TITLE DATE It PAY IVI ENS' RECEIVED , n j I DEC x:8:;2008 "3 SAN JOAQUIN COUN ENVkRONMENTAL _, T HEAL-TH DEPARTMEN �1 TME NT USE ONLY Application Aeccpte Dile Area Destruction Inspection By Dale Employee IDh COMMENTS O / � y a- PE SC Received Chec I Amount Date Permit! Invoice# Well!D# Codes Info 8 emitted Service Request# EHD 43.62-005 w,lk flcslrlouion Pc it 112]11005