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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 yy��yEEpXppPIRES 1 YEAR FrROM DATE ISSUED e- Ill�V� 7 JOB ADDRESS L� - V CITYIZIP m CROSS STREET CA 11 ✓O APN ✓� PARCEL SIZEV___1LAND USE APPLICATTIIIO(N�## Y OWNER __VttUV �r) PHONE l •�L J - -112 - O-✓ ✓ � A OWNER ADDRESS 01 0 12- CITY/STATE/ZIP to , fL �i�4gQ�1 r �r CONTRACTOR 1 1Y PHONE r CONTRACTOR ADDRESS \ S CITY/STATE/ZIP {�yQV � lA C-57 WELL DRILLING LICENSE NUMBER EXPIRATION DATE 171, '/o. 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 rel Open Bottom ❑ Gravel Pack ❑ Uncased ❑ Other _Well Log copy attached ❑ Yes No Grout Seal ❑ No ❑ Yes _ _It below ground surface(bgs) Hole Diameter inches Well Conductor Casing ❑ Yes No Depth of Conductor Casing _ ft b s Diameter of Conductor Casing inches Well Casing Diameter___inches Total Depth 1 It Depth to Water_ ` It Depth of Casing It bgs DESTRUCTION SPECIFICATION Sealing Material from 0_ ft bgs to _ ft bgs Filler Material / from - It 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 Sealing Material Neat Cement(94 Ib bag/5-6 gal water) Sand Cement sack mix/7 gal water X Bentonite Pellets Bentonite(20%solids) Manufacturer Spec%solids_ Name Specs on File Specs Submitted Placement Method Pumped Free Fall Other Seal Completion)C' Complete with Mushroom Cap 2 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 1 AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION LAWS. uu 0 MINIMUM)d HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS CONTRACTORS SIGNATURE TITLE DATE ...�¢�...._ ......._. ......;. ... ._ ......_._. _.... ... _ .. ._ .. _....._... ...... _. ... ........ .... - ..- - _.._ ........ F {....__ .. .. ............... ...... _ _ .. ... _._._......... ............. ... .. ....-. .._ ._a. __.....__ I_.. __..._..._ __ .._.. _...._. _...._ _._.__._._...._ .._._..._....._.__..__._...__........... ...._._.__ _.._ _.__.--J]--- ___ i S�Ao 2 3 209 H ENVl04UlN C ROU - -._,—._........._ E9LT NMF IV N p NrgC DEPARTMENT USE ONLY �y c, Application Accepted By. � _ Date �- 73 -2-0 1 1 Area Destruction Inspection By n {�_ Date_q I /Z--+ ! Employee ID# �� Lit'✓ COMMENTS t aC S VIXX Jif PE SC ReceivedCheck Amount Date Permit/ Invoice# Well ID# Codes Info Cash Remitted Service Request# Frin 49-08 WELL DESTRUCTION PERMIT