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WELL DESTRUCTION PERMIT PUBLJC 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! c EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS t70 1 V `._10 "1 1, CITY/ZIP r-..->ra 1C✓" CROSSSTREET f G +'(Q? I APN 2 7. 7-Y oO '//'L' PARCEL SIZEItaVAND USE APPLICATION If O OWNER LJ<?rY,.�r'�tf�.. C-_ts..�'S.h F'1 .�0. PHONE OWNER ADDRESS 'D.c' P- CITY/STATE/ZIP ,i1,w.� r•"'�; -" CONTRACTOR VO /45.f, I '. - v;i y' or PHONE Z 7 I CONTRACTOR ADDRESS ! {11 C+/ CIN/STATEIZIP J C-57 WELL DRILLING LICENSE NUMBER EXPIRATION DATE PERFORATION CONTRACTOR PHONE PERFORATION CONTRACTOR ADDRESS CINISTATE/ZIP ❑ C-57 Well 4rilling 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 Ex�l ❑ California Occupational Safety Health-Blaster License Number E REASON FOR DESTRUCTION Dry f,Replacement Well ❑ Caved In ❑ Pit Well ❑ InactivC ❑ Test e Detected/Suspected Well Water Contaminant(s) SCEP n 9 ;g Adjacent property with contamination(Address) Known Soil/Water contaminants at adjacent property 1/1N CO TAF EXISTING WELL CONSTRUCTION DETAILS ❑ Open Bottom Gravel Pack ❑ Uncased ❑ Other T Well Log copy attached ❑ Yes No -Grout Seal ❑ No ❑ Yes it below ground surface(bgs) Hole Diameter w Inches Well Conductor Casing❑ Yes 1.No Depth of Conductor Casing fj gs Diameter of Conductor Casing Inches Well Casing Diameter=4 inches Total Depth ,,, ft Depth to Water tJt� it Depth of Casing it bgs DESTRUCTION SPECIFICATION .Y Sealing Material from ,�� ft bgs to i./ it bgs Filler Material from ft bgs to ft bgs Well casing to be perforated by one of the following methods: from it bgs to ft bgs ❑ Mills Knife Number of cuts every ft and/or ❑ Explosives❑ Detonating cord ❑ with projectiles every it ❑ without projectile ❑ Detonating cord and boosters ❑ with projectiles every it ❑ without projectile ❑ Other Sealing Material ❑ Neat Cement(94 Ib bao-6 gal water)❑ Sand Cement sack mdx/7 gal water ❑ Bentonite Pellets 'X Bentonite(20(^y<s�olids) ❑ Manufacturer Spec%solids_% Name Ll Specs on File ❑ Specs Submitted Placement Method PPumped ❑ Free Fall ❑ Other Seal Completion ❑ 'Complete with Mushroom Cap it bgs ❑ Complete to Existing Surfage 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. lv MININI!!MW HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS / CONTRACTORS SIGNATURE ��"�<"'+,.,� TITLE DATE I 'a jel s v ti D1EPARTMENT USE ONL Application Accepted By /U /�✓ .._.i '\�` Date Area ll.� Destruction Inspection By Date Employee ID# "� !,kal COMMENTS PE SC Received ,Chet Amount PermIV Code Info B =_ Cash emitted Date Service Request# Invoice# Well ID# EHD'43-08 WELL DESTRUCTION PERMIT