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I`'VLL DESTRUCTION PERMIT SCANNED `go ♦NO PUBLIC WATER SYSTEM 0 Yes SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE 3" FL-STOCKTON CA 95202 - (209)468-3420 NON-REFUNDABLE PERMIT CALL(209)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED �J'] to JOB ADDRESS a( 6 CITY/ZIP L b�1 CROSS STREET 13—/7 01'e' ✓ APN U - 3 Z S g PARCEL SIZE -92 LAND USE APPLICATION OWNERN ICL G PHONE y OWNER ADDRESS _ CITY/STATE/ZIP CONTRACTOR A 4 4 &-t.°S S / I�/., � PHONE CONTRACTOR ADDRESS. / •G 7 r'-( /el-n E�dr c��< CITYISTATE/ZIP Ie+- C-57 WELL DRILLING LICENSE NUMBER EXPIRATION DATE. PERFORATION CONTRACTOR PHONE 3 3 `A ` Z 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 El 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(s) Adjacent property with contamination (Address) Known Soil/Water contaminants at adjacent property N EXISTING WELL CONSTRUCTION DETAILS ❑ 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 ti bgs Diameter of Conductor Casing inches Well Casing Diameter. 91 inches Total Depth_;Z-3 ft Depth to Water L ___ ft Depth of Casing ft bgs DESTRUCTION SPFCIFICATION t Sealing Material from fl bgs to 3 ft bgs Filler Material /3C A {ate,'7r- e A t 75from 2-5 ft bgs to 3 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 ti and/or ❑ Explosives ❑ Detonating cord ❑ with projectiles every ft ❑ without projectile ❑ Detonating cord and boosters ❑ with projectiles every ft 13without projectile ❑ Other Sealing Material ❑ Neat Cement(941h bag 15-6gal wafer) ❑ Sand Cement sack mis/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 L4g:-k d-5 ..)7` 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. 1 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. _M//,r1'�NIMUM 4 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS 7 CONTRACTORS SIGNATURE /�" v § TITLE 07-V 7'��L DATF Z-- ?' Z�/ Xll PAYMENT RECEIVED H FEB - 8 2007 �` saH Joanul»CC)UN Y r ENVIRONMENTAL - �:� HEALTH DEPARTMENT