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ELL DESTRUCTION PERMI- A" PUBLIC WA'fc " SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE 3""FL-STOCKTON CA 95202 - (209)468-3420 NON-REFUNDABLE PERMIT CALL( 09)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED J08 ADDRESS CITY/ZIPV ac �� `� �t� tin CROSS STREET J zfzl APN /1 7 r(J / 0---3 0 PARCEL SIZE.L-3 LAND USE APPLICATION# OWNER 42PHONE 7�� OWNER ADDRESS CITY/STATE/ZIP (sYC+� CONTRACTOR r PHONE 4e-" ;2 — CONTRACTOR ADDRESS !] C[TYISTATE/ZIP AC-57 WELL DRILLING LICENSE NUMBER 3 � / D s(,(_) EXPIRATION DATE PERFORATION CONTRACTOR PHONE PERFORATION CONTRACTOR ADDRESS CITY/STATE/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 Contaminant(&) Adjacent property with contamination (Address) Known Soil I Water contaminants at adjacent property EXISTING WELL CONSTRUCTION DETAILS )d Open Bottom ❑ Gravel Pack ❑ Uncased ❑ Other Well 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 inches Total Depth 7 ft Depth to Water ft Depth of Casing ft bgs DESTRUCTION SPECIFICATION Sealing Material from �ft bgs to IQ fi bgs Filler Material from ft bgs to ft bgs Well casing to be Derforated by one of the following methods: from ft bgs to ft bgs ❑ Mills Knife Number of cuts every ft and/or ❑ Explosives ❑ Detonating cord ❑ with projectiles every ft ❑ without projectile ❑ Detonating cord and boosters ❑ with projectiles every ft ❑ without projectile ❑ Other Sealing Material ❑ Neat Cement(94 Ih bag/5-6 gat water) X Sand Cement sack mix 17 gal water ❑ Bentonite Pellets ❑ Bentonite(20%solids) ❑ Manufacturer Spec%solids % Name ❑ Specs on File ❑ Specs Submitted Placement Method ❑ Pumped ❑ Free Fall ❑ Other Seal Completion M� Complete with Mushroom Cap ft 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 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 A `CE NOTICE REQUIRED FOR INSPECTIONS CONTRACTORS SIGNATURE TITLE ��C- J DATE Z-77-2 l ' ., 920 4- A/V 05 HE'gLTH 0 V A4 O(N j; DEPARTMENT USE ONLY � g Application Accepted By Date "z2 � Area / r Destruction Inspection By Date 7T/,7.5-/o.4 _ _ _ Employee ID# tti COMMENTS 70 i r r PE Sc Received heck#1 Amount Date Permit/ Invoice# Weil ID# Codes Info By Remitted Service Request# 5; EHD 43-02-DON Well Destruction Permit 112712005