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WELL DESTRUCTION PERMIT V PUBLIC WATER SYSTEM ❑Yes r5fNo i 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 1 YEAR FROM DATE ISSUED r JOB ADDRESS 1046CI t SOL4W A4ACITY/ZIP f CROSS STREET / F Lts�i APN 650DFARCEL SIZE LAND USE APPLICATION# OWNER �t>�iL�`�l ' f�� /' f Lti1✓Jl�r/ �� PHONE f OWNER ADDRESS_ (��nj� �xJ \"11G1N�. CITY/STATE/ZIP M9LAA//`� r CONTRACTOR Macttill D t`l� f ,=1sC PHONE SzZ- I�JZS -T T-- CONTRACTOR ADDRESS 1 Ln A RA CITY/STATE/ZIP kC-57 WELL DRILLING LICENSE NUMBER ITa( tt(_2?i EXPIRATION DATE 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 ' ry ❑ CHP Hazardous Material Transportation for Explosives License Number Expiration ❑ San Joaquin County Sheriff-Coroner Explosives Application and Permit License Number Expiration ❑ California Occupational Safety Health-Blaster License Number Expirati to REASON FOR DESTRUCTION Dry Replacement Well ❑ Caved In ❑ Pit Well ❑ InactivgS,% ❑ T o?i, Detected/SUspected Well Water Contaminant(s) '�V✓Oq Adjacent property with contamination (Address) EA ON OU Known Soil/Water contaminants at adjacent propertyp�R7-4fe NT EXISTING WELL CONSTRUCTION DETAILS ❑ Open Bottom Gravel Pack ❑ Uncased ❑ Other Well Log copy attached El Yes No Grout Seal ❑ No ❑ Yes _ _ It below ground surface(bgs) Hole Diameter inches Well Conductor Casing ❑ Yes V No Depth of Conductor Casing It bgs Diameter of Conductor Casing inches i Well Casing Diameter_ —inches Total Depth If Depth to Water__It Depth of Casing _.It bgs DESTRUCTION SPECIFICATION Sealing Material from ft bgs to 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 everyft 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 bag/5-6 gal water) Sand Cement sack mixl7 gal water Bentonite Pellets 'C Bentonite(20%\ solids) Manufacturer Spec%solids. % Name Specs on File Specs Subm tted Placement Method 1,( Pumped Free Fall Other Seal Completion Complete with Mushroom Cap It 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. •C) 10 MR ADVANCE NOTICE REQUIRED FOR INSPECTIONS CONTRACTORS SIGNATURE TITLE e,-' .v+e/ DATE E �A� ... X ...... i 0 _11 --._................. __ _. __ _ . r .. _....... D,EEPPAARTMENT USE ONLY tt Application Accepted By ��`��'� _ Date � -,13 ` t Area 3 Destruction Inspection By _ _ _ Date 5 Employee ID# GUI, COMMENTS 2 V,/ PE SC Received ec Amount Permit/ Codes Info B a Remitted Date Service Request# Invoice# Well ID# '0 1(71 1�;vo '37 � W Poch q�� EHD 43-08 WELL DESTRUCTION PERMIT 4/30/12