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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 1 YEAR FROM DATE ISSUED JOB ADDRESS 1 I(, `m 11 1 1 CITY21P t/1 -� 4'A 61`7-5 J �l CROSSSTREET "' APN S {� nr / PARCEL SRE/V--ILAND�USS�E APPLICATION#/� OWNER f 1`J7n1A1V'i'T` \�!/l 1 1�.� 1�% '• "r'1" '•" �� PHONE "12yr1j•( L/2!'-/' �y��y OWNER ADDRESS 1/„„`� '11 %�/X ?�Y✓ {C INC) CITY/STATE21P tl Id Vlft Q 'FI✓ 7'4,12)I CONTRACTOR 1V��1,,?`L/'��` �;x-11` y-i I IVC/ PHONE v� FiONTRACTOR ADDRESS i``''� 1 i i€�W�� V-A i(� 1A1nn CITY/STATE/ZIP-rill k)(-kt`,�i) ;47 ✓��/i?J , XC-57 WELL DRILLING LICENSE NUMBER U' W f l U+ EXPIRATION DATE I) n 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 Dale ❑ 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 ';51�No Grout Seal ❑ No ❑ Yes it below.ground,surface(bgs) Hole Diameter_Inches Well Conductor Casing❑ Yes '3K No Depth of Conductoj Casing-ftbgs r Diameter of Conductor Casing Inches Well Casing Diameter_.__inches Total Depth .It Depth to Water ft Depth of Casing--it bgs DESTRUCTION SPECIFICATION Sealing Material from _ _ft bgs to 52- it 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 It ❑ without projectile ❑ Detonating cord and boosters ❑ with projectiles every It ❑ without projectile ❑ Other ` Sealing Material F Neat Cement(94 Ib bag/5-6 gal water)-1 Sand Cement sack mIx17 gal water ><Bentonite Pellets G Bentonite(20%solids) ❑ Manufacturer Spec%solids_% Name ❑ Specs on File - Specs Submitted Placement Method ❑ Pumped r 1 Free Fall ❑ Other Seal Completlon)4 Complete with Mushroom Cap_� 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. MINIMUM 491HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS CONTRACTORS SIGNATURE - -+ _TITLE b r ,>> DATE 1 - I I b - 1 _ - DEPARTMENT USE ONLY Application Accepted By '1�^��' "t �� { Date -U I ( Area Destruction Inspection By f Date Employee ID# 4 COMMENTS I A!rC (S Yl 2212 Lp 11 "J tok PE SC Received Check'# Amount Permit/ Date Invoice# Well ID# Codes Info B as Remitted Service Request# FHD046 WELL DESTRUCTION PERIMIT