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WELL DESTRUCTION PERMIT 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 7 YEAR FROM DATE ISSUED JOB ADDRESS 27100 E. Flood Road CIN/ZIP Linden, CA 95236 m CROSS STREET ESCALON BELLOTA APN 093-290-01 PARCEL SIZE 80 LAND USE APPLICATION# c OWNER Anthony Gandolfo PHONE y y OWNERADDRESS 27100E Flood Rd CITY/STATE/ZIP Linden, CA 95236 CONTRACTOR SJC Department of Public Work PHONE_ (209)468-3000 CONTRACTOR ADDRESS 1810 E. Hazelton Ave CITY/STATE/ZIP Stockton, CA 95205 ❑ C-57 WELL DRILLING LICENSE NUMBER N/A EXPIRATION DATE PERFORATION CONTRACTOR N/A PHONE PERFORATION CONTRACTOR ADDRESS N/A CITYISTATE/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 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 Contaminants) Adjacent property with contamination(Address) Known SoiWyater contaminants at adjacent property EXISTING WELL CONSTRUCTION DETAILS ❑ Open Bottom ❑ Gravel Pack ❑ Uncased ❑ Other Well Log copy attached ❑ Yes ❑ No Grout Seal ❑ NO ❑ Yes It 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 inches Total Depth It Depth to Water It Depth of Casing ft bgs DESTRUCTION SPECIFICATION Sealing Material from ft bgs to ft bgs Filler Material from It bgs to ft bgs Well casing to be perforated by one of the following methods: from ft bgs to It bgs ❑ Mills Knife Number of cuts every ft and/or ❑ Explosives ❑ Detonating cord ❑ with projectiles everyft ❑ without projectile ❑ Detonating cord and boosters ❑ with projectiles everyft ❑ without projectile ❑ Other Sealing Material Neat Cement(94 lb bag/5-6 gal water)❑ Sand Cement sack mix17 gal water Bentonite Pellets Bentonite(20%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 I HEREBY CERTIFY THAT 1 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. MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS CONTRACTORS SIGNATURE FOR DOCUMENTATION ONLY TITLE DATE 2190-11s . 4kzsA•T/SZ+?Q 7 .ems A CSC-hof rr�z- s u �a✓�"rfr�d 7ys 8d/7r✓rl �'Cfzl�tzL 1�5'<. erZe�r1+zy4 qct; �s/�IZ�rWr s/i.� �s cr Z-yECu Etc Z4Ce gA -mss .rtz�ua3 Td estray sow ZEzVe ZK�feci✓Zlzv/��) y)r�Gr'f5 d2c•c�J ZIT eenP��/b1c�G F7q/rlc�/lZ- PRpta zaa)� J / ¢ 7�G�-�� r ca for=«za-�-� • H��,L-1z�J. 1 DEPARTMENT USE ONLY Application Accepted By F ID P�C ��Dr NI 4T'{Q*1(Jh m iy Date Area Destruction Inspection By Date 7— .3 Employee ID# COMMENTS PE so ReceivedCheck#I Amount Date Parm lt/ Invoice# Well ID# Codes Info B Cash Remi Service Request 0 EHD 43-08 WELL DESTRUCTION PERMIT 4/30112