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WELL DESTRUCTION PERMIT <br /> PUBLIC WATER SYSTEM 0 Yes 0 No <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE 3`°FL-STOCKTON CA 95202 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL(209)953-7697 FOR INSPECTIONS E PIRES I YEAR FROM DATE ISSUED <br /> :n <br /> JOB ADDRESS .� �� CITY/ZIP > <br /> �J� /�� Y <br /> CROSS STREET APN PA RCEI.SIZE j,3L ND US APPLICATION# <br /> v <br /> // / 6�� <br /> OwNER_�JOGCtn .Kill= Sup PHONE — 3 6K 1 <br /> OWNER ADDRESS C j CITY/STATE/ZIP <br /> CONTRACTOR •" PHONE. <br /> CONTRACTOR ADDRESS CITY/STATE/ZIP <br /> C-57 WELL DRILLING LICENSE.NUMBERS EXPIRATION DATE <br /> PERFORATION CONTRACTOR PHONE <br /> PERFORATION CONTRACTOR ADDRESS CITY/STATE/ZIP <br /> C-57 Well Drilling License Number Expiration Date <br /> ❑ Bureau of Alcohol,Tobacco and Firearms-Users of High Explosives License Number Expiration Date <br /> ❑ CHP Hazardous Material Transportation for Explosives License Number Expiration Date <br /> ❑ San Joaquin County Sheriff-Coroner Explosives Application and Permit License Number Expiration Date <br /> ❑ California Occupational Safety Health-Blaster License Number Expiration Date <br /> REASON FOR DESTRUC-110N ❑ Dry Replacement Wel) ❑ 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 /> EXISTING W ELL CONSTRUCTION DETNA.I�LS ,Open Bottom ❑ Gravel Pack ❑ Uncased El Other <br /> Well Log copy attached ❑ Yes . No Grout Seal ❑ No ❑ Yes _fl below ground surface(bgs) Hole Diameter inches <br /> Well Conductor Casing ❑ Yes No Depth of Conductor Casing it bgs Diameter of Conductor Casing inches <br /> Well Casing Diameter _inches Total Depth it Depth to Water:3,C)— it Depth of Casing fl bgs <br /> DESTRUCTION SPECIFICATION <br /> Sealing Material from_ _ft bgs to S _ft bgs Filler Material _ from R bgs to ft bgs <br /> Well casing to be verforated by one of the following methods: from ft bgs to H bgs }� <br /> ❑ Mills Knife Number of cuts every fl and/or <br /> ❑ Explosives ❑ Detonating cord ❑ with projectiles every_, 11 ❑ without projectile <br /> ❑ Detonating cord and boosters ❑ with projectiles everyft ❑ without projectile <br /> ❑ Other <br /> Sealing Material [3 Nest Cement(94/h hag/5-6 gal water) ❑ Sand Cement suck m x/7 gal water Bentonite Pellets <br /> ❑ Bentonite(20%solids) ❑ Manufacturer Spec%solids—% Name ❑ Specs un File ❑ Specs Submitted <br /> Placement Method❑ Pumped,>qL Free Fall ❑ Other <br /> Seal Completion ❑ Complete with Mushroom Cap _ _It bgs ❑ Complete to Existing Surface Pad <br /> I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND,RULES AND REGULATIONS. 1 ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> MINIM1 UM 24 HOUJ2 ADVANCE NOTICE REQUIRED FOR INSPECTIONS /ate <br /> CON-TRACTORS SIGNATURE_y /�J1,ti-� TITLES T� r DATE �t'� <br /> /4c1.) <br /> ,A,tc� 014 <br /> 3\3 COUN" <br /> SAN NVIROUNIMENMF W <br /> U S E O N L Y <br /> Application Accepted B, Date_ Area <br /> Destruction Inspeclio y Date Employee IDri Z% <br /> COMMENTS <br /> PE SC Received Amount Date Permit/ Invoice# Well ID# <br /> Codes Info B Cash Remitted Service Request 4 <br />