Laserfiche WebLink
t � LL DESTRUCTION PERMI <br /> _ PUBLIC WATER SYSTEM ❑Yes 1d1%SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AvE 3""FL-STOCKTON CA 95202 - (209)468-3420 <br /> NON—REFUNDABLE PERMIT CALL t209)953_7697 FOR INSPECTIONS EXPIRES I YEAR FROM DATE ISSUED <br /> JOB ADDRESS �, Q CITYIZIP �ln <br /> r� <br /> CROSS STREET S n APN �� q (O2-0=�.? PARCEL SIZE�'Z�gND USEAPPLICATION# O <br /> W �/v yQ}� -Z Q <br />' OWNER /� _.. 1_R�iE ,/� ,�z��.L <br /> 72 <br /> OWNER ADDRESS . 11 C Q1QLV CITY/STATE/ZIP fS QIJQLQC�IJCIti1 7 <br /> CONTRACTOR C �^-7` PHONE ��`/�'aF�j <br /> CONTRACTOR ADDRESS 3_&� G-� �1��0� zd CITY/STATE/ZIP / pLI,t1' (�� G✓�/ g�`z I <br /> IIS C-57 WELL DRILLING LICENSE NumBER "1 EXPIRATION DATE r f -Z1 4D O <br /> PERFORATION CONTRACTOR PHONE <br /> PERFORATION CONTRACTOR ADDRESS CITY/STATE/ZIP <br /> ❑ C-57 Well Drilling License Number pir b <br /> ❑ Bureau of Alcohol,Tobacco and Firearms-Users of High Explosives License Number Ea <br /> ❑ CNP Hazardous Material Transportation for Explosives License Numberpiration Date' <br /> 0 San Joaquin County Sheriff-Coroner Explosives Application and Permit License Number Exp] tion Ivn Date <br /> ❑ California Occupational Safety Health-Blaster License Number - Expirat n Date <br /> REASON FOR DESTRUCTION ❑ Dry ❑ Replacement Well ❑ Caved In ❑ Pit Well Inactive © Test Hole <br /> Detected/Suspected Well Water Contaminant(s) <br /> Adjacent property with contamination (address) <br /> Known Soil/Water contaminants at adjacent property <br /> 111 <br /> EXISTING WELL CONSTRUCTION DETAILS ❑ _Open Bottom p/6 ravel Pack ❑ Uncased ❑ Other <br /> Well Log copy attached ❑ Yes : ❑ Grout Seal El' No Yes ft below ground sce(bgs) Hole Diameter- inches <br /> Well Conductor Casing ❑ Yes No Depth of Conductor Casi ft bgs iameter of Conductor Casing inches <br /> Weli Casing Diameter 1 inches Total Depth=ft Depth to Water ft Depth of Casing ft bgs <br /> DESTRUCTION SPECIFICATION <br /> Sealing Material frdm ft bgs to ft bgs Filler Material from ft bgs to ft bgs <br /> Well casing to be perforated by one of the f0ll0wi0methods: from ft bgs to ft bgs <br /> ❑ Mills Knife Number of cuts every ft and/or <br /> ❑ Explosives ❑ Detonating cord ❑ with projectiles everyft ❑ without projectile <br /> ❑ Detonating cord and boosters ❑ with projectiles everyft ❑ without projec.' <br /> ❑ Other <br /> Sealing Material ❑ Neat Ceme (94!h hag/S-h ga!water) ❑ Sand Cement sack mix/7 gal w ite Pellets <br /> ❑ Bentonite(20%solids) Manufacturer Spec%solids_% Name ❑ S ec <br /> Placement Method ❑ urn ❑ Free Fall ❑ Other <br /> Seal Completion C plete with Mushroom Cap ft bgs g plete�o Ex�ting Surface Pad ��eL O+YW+4y <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE ORK WILL BE DON E WITH SAN <br /> JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. 1 A Y THAT MY REQUIRED LICENSE 1S <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT 1 AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> MINIM 24 UF�,A NCE NOTICE REQUIRED FOR INSPECTIONS <br /> CONTRACTORS SIGNATURE TITL �� ATE S 2— 4� <br /> J_ <br /> i <br /> E <br /> KK. qm <br /> l f _ . 2 <br /> 0.08 <br /> t t s <br /> , <br /> A <br /> Al <br /> a _ l 1ME <br /> I I g H H EPq RNTNT <br /> INCOUNTYA <br /> E <br /> .. _._,.__� } _L_..., _„ <br /> DEPARTMENT USE ONLY <br /> Application Accepted By Date :S Z Area <br /> Destruction Inspection By Date < Employee ID# Ta <br /> COM E ; <br /> PE SC Received e ! Amount Permit/ <br /> Codes Into By sh Remitted Date Service Request# Invoice# Well ID# <br /> 3 & � � as 5'p .L-riS 0$ <br /> EHD 43-02-008 <br /> 1/27/2005 Well Destruction Permit <br />