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ELL DESTRUCTION PERM - PUBLIC WATER SYSTEM ❑Yes ❑No SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE 3""FL-STOCKTON CA 95202 - (209)468-3420 NON-REFUNDABLE.PERMIT CAL 09)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESSGT7 t CITY/ZIP a { C -6� PARCEL Sl7F- - LA� SE APPLICATION# G 01 CROSS STREETy APN a .`.�✓-7 / 7c OWNER L t7 o C � PHONE ad OWNER ADDRES CITYISTATEIZIP - CONTRACPO � PHONE �q -- CONTRACTOR ADDRESS CITYISTATEIZIP L✓"� t L� 1 /w&C - C-57 WELL DRILLING LICENSE NUMBER �� EXPIRATION DATE PERFORATION CONTRACTOR PHONE PERFORATION CONTRACTOR ADDRESS CITYISTATE/Z!P I ❑ 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 I ❑ San Joaquin County Sheriff-Coroner Explosives Application and Permit License Number Expiration'Date ❑ California Occupational Safety Health-Blaster License Number Expiration Date i REASON FOR DESTRUCTION _-AWDry [3Replacement Well ❑ Caved In ❑ Pit Well inactive ❑ Test Hole Detected 1 Suspected Well Water Contaminant(s) Adjacent property with contamination (Address) Known Soil l Water contaminants at adjacent property EXISTING WELL CONSTRUCTION DETAILS ❑ Open Bottotii ❑ Gravel Pack ❑ Uncased ❑ Other Well Log copy attached ❑ Yes>4 No gout Seal ❑ No ❑ Yes ft below ground surface(bgs) Hole Diameter inches Well Conductor Casing ❑ Yes,7d No Depth of Conductor Casing ft bgs; Diameter of Conductor Casing inches Well Casing Diameter inches Total Depth//'X- ft Depth to Wate V2 ft Depth of Casing ft bgs DESTRUCTION SPECIFICATION - 1 Sealing Material from ft bgs to ft bgs Filler Material �L from ® ft bgs to ft bgs Well casing to be perforated by one of the following methods_ from ft bgs to ft bgs ❑ Mills Knife Number of cuts every ft and I or 13Explosives ❑ Detonating cord ❑ with projectiles every ft ❑ without projectile ❑ Detonating cord and boosters ❑ with projectiles every ft ❑ without projectile ❑ Other Sealing Material ❑ Neat Cement(941h bag/5-6 gal water)7;Rf Sand Cement / sack mix I7 gal water d Bentonite Pellets ❑ Bentonite(20%solids) ❑ Manufacturer Spec%solids % Name ❑ Specs on File ❑ Specs Submitted Placement Method ❑ Pumped;K Free Fall ❑ Other Seal Completion Air_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. MI IM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS CONTRACTORS SIGNATURE TITLED ,I'i;.rlE DATE 4 A�-� 3 -- 1 I , 'T �O(� YA ,�,- 1`] H �COL}N� s SA V4FiONMIsL ..i. ._':��. ._-_.-_�'".,-_ _._.E .m��_w�,.�.� .i___l�.��_, .-.� �.__��__ �_ ._�_��._••�- -If•___¢ i---�-}-.1>AI��f~PAR�MENT � • Im t � � i � s _ - - _- - - - - E ,T ENT�USE ONL Application Accepted By ' Date Area Destruction Inspection By 2 Date / Employee ID# COMMENTS 0d i ri '.�o�.ate% r—�� w f2 r I PE SC Received Check#/ Amount. pate Permit/ invoice# Well Codes Info B as Remitted Service Request# IN Poo EHD 43-02-OOK Well Destruction Permit 1127/20P5