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ELL DESTRUCTION PERMIT ! PUBLIC WATER SYSTEM ❑Yes Flo SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 600 E MAIN STREET-STOCKTON CA 95202 - (209))4683420 y NON-REFUNDABLE PERMIT CALL 209 953-/7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED JOBADDRESS_ b Zg �:.tJ�/Y G+ r1 -(2 • -- CITY/ZIP Lm �J SZ �tl CROSS STREET Lam✓ a V —A APN J op "070 62-3 PARCEL SIZE LAND USE APPLICATION# OWNER. LL M"� fF I/ PHONE Z uu m OWNER ADDRESS 1/I -2- a!L L/ 7 L] CITYISTATEIZIP L_a4/ - @ '45'Z-14 0 CONTRACTOR >ti�to ��-t edi I e �n_�4 �+ y/ PHONE 3.Z) -�1 Ld _-- CONTRACTOR ADDRESS 1 CITY/STATEIZIP la I Lf C-57 WELL DRILLING LICENSE NUMBER `u NQS 12,3 EXPIRATjON DATE, Jh/ I PERFORATION CONTRACTOR PHONE PERFORATION CONTRACTOR ADDRESS CITY/STATEIZIP ❑ C-57 Well Drilling License Number Expiration Date ❑ Bureau of Alcohol,Tobacco and Firearms-Users of High Explosives License Number Expiration Date ❑ CNP 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 j-Dry ❑ Replacement Weil 0 Caved In Pit Well ❑ Inactive ❑ Test Hole Detected/Suspected Well Water Contaminant(s) Adjacent property with contamination(Address) Known Soil/Water contaminants at adjacent property I EXISTING WELL CONSTRUCTION DETAILS ❑ Open Bottom ❑ Gravel Pack ❑ Uncased ❑ Other Well Log copy attached D 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 r� Well Casing Diameter inches Total Depth ft Depth to Water ft Depth of Casing ft bgs DESTRUCTION SPECIFICATION L r -544-77— Sealing j44-77-Sealing Material from ft bgs to-7 ft bgs Filler Material - *+ from O ft bgs to :2 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/or ❑ Explosives ❑ Detonating cord ❑ with projectiles everyft ❑ without projectile ❑ Detonating cord and boosters © with projectiles everyft ❑ without projectile Q Other Sealing Material ❑ Neat Cement(94 lb bag/5-6 gal water)❑ Sand Cement sack mix/7 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 I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RALES 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. 1 INIMUM 4 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS j CONTRACTORS SIGNATURE TITLE DATE 3/IG/ 27&&7 ' . I i J T F �. , sw -.. # ... ! � 1 � {,,,:„../�^_� ��•� M I�1 i,A.}.@��..,_ { t ��.....� �� —.T.6--' UIJ;] �. I. R 4 i _ QU IlqiCool M :N--rqL IT Do t411 � EPARTMEN7 USE ONLY LF Application Accepted BC Date f G+ O Area 9G Destruction inspection _.Ce Date O� Employee ID#_s" COMMENTS te— C3 -S�O - CE1ifa� . 1-19 C' PE SC Received QgbgAmount Date Permit/ Invoice# Well ID# Codes Info By Cash Remitted Service Request# 05 1G-7-7 EHD 43.08 /�/( � WELL DESTRUCTION PERMIT 10/5107 }