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WELL DESTRUCTION PERMIT PUBLIC WATER SYSTEM ❑Yes ❑No SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 East Hazelton Avenue-STOCKTON CA 95205 - (209)468-3420 NON-REFUNDABLE/PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 11 YEAR FROM DATE ISSUED JOB ADDRESS �i 5i- CITY/ZIP �r G h G) ('d ✓ i e y5" 3) CROSS STRE & S71- APN —k36- / PARCEL SIZEd LAND USE APPLICATION# � OWNERa-w► ,�rfr'hC\ V �Ct Oi ff �( PHONE_2-0 6l.'� - ��3� OWNER ADDRESS � �3 6 G 2-^ [(��✓7_ CITY/STATE/ZIP �v e n C'At, CONTRACTOR C e s4- ( ey-24 f��D/t)�G�Y1a V�,�L PHONE 20 el�`-224 1 c CONTTRACT ADDRESS P O 6� ' ;'� CITY/STATE/ZIP >-• S 310 W C-57 WELL DRILLING LICENSE NUMBER 7J,�� 1 EXPIRATION DATE U PERFORATION CONTRACTOR PHONE PERFORATION CONTRACTOR ADDRESS CITY/STATE/ZIP ❑ 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 ❑ 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 EXISTING WELL CONSTRUCTION DETAILS� ❑ Open Bottom ❑ Gravel Pack ❑ Uncased ❑ Other Well Log copy attached ❑ Yes M-'5. Grout Seal ❑ No ❑ Yes It below ground surface(bgs) Hole Diameter inches Well Conductor Casing ❑ Yes M- Depth of Conductor Casing _ft bgs Diameter of Conductor Casing inches Well Casing Diameter__' inches Total Depth__�_ It Depth to Water_ 60fft Depth of Casing ft bgs DESTRUCTION SPECIFICATION Sealing Material from _� _ft bgs to 0 ft bgs Filler Material 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/or _ ❑ Explosives ❑ Detonating cord ❑ with projectiles every ft ❑ without projectile ❑ Detonating cord and boosters ❑ with projectiles every ft ❑ without projectile ❑ Other Sealin aterial Neat Cement(94 Ib bag/5-6 gal water) Sand Cement sack mixll gal water Bentonite Pellets Bentonite(20%soli Manufacturer Spec%solids--_-_—% Name Specs on File Specs Submitted Placement Method Pumped rFree Fall Other Seal Completion Complete with Mushroom Cap 3 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. IY8 MOUR V CE NOTICE REQUIRED FOR INSPECTIONS CONTRACTORS SIGNATURE INIM v TITLE ✓t2ll— DATE ro y t � < JLU z. N ' OV Ld UJ LU o __ a y,, V ... .. .......o _.... . -- .-- --- I I D ARTMENT USE ONLY Application Accepted By _ _ Date Area I kq Destruction Inspection By Date Employee IN COMMENTS PE SC Received Check#/ Amount Date Permit/ Invoice# Well ID# od I1`1fo B Cash Remitted Service Request# 4 o 17 / (Q '-1 le_ i — EHD 43-08 WELL DESTRUCTION PERMIT 4/30/12