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WELL DESTRUCTION PERMIT PUBLIC WATER SYSTEM ❑Yes ❑No SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPT / J G1868 East Hazelton Avenue-STOCKTON CA 95205-6232-(209)468-3420 NON-REFUNDABI F PPiCALL 209 953-7697 FOR INSP IONS EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS 111099". VNJ ') (J O�C 21Pi/414 Rm/- / �/ `� I t3 -,"i,•, CROSS STREET ,,lr��O`J t \ 1Q�(' GG APN `PA�R//CC�EL SIZE�LAND(U.SE APPLICATION#'7 (� 9Q? � OWNER'rIy/ C/!� / �J� •CYl R.r O c2/.f� S'LG C S/6 —/�_/,^{ 7l O ' rvAn OWNERADDRESS !FMJ A NSC uGl /SAT�/ZIP � (/ J"� CONTRACTOR V 4f \ I PHONE p +++�///yyy 3 / 2 6 CONTRACTOR ADDRESS S" , Q CITYISTATE21P� , 1 1 O CAL C-57 WELL DRILLING LICENSE NUMBER �� ExPIRATION DATESL ( � PERFORATION CONTRACTOR PHONE PERcrl�ATION CONTRACTOR ADDRESS CITYISTATEIZIP C-57 Well Drilling License Number Expiration Date Bureau of Alcohol,Tobacco and Firearms-Users of High ExplRsives 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 nactive ❑ Test Hole Detected/Suspected Well Water Contaminants) Adjacent property with contamination(Address) Known Soil/Water contaminants at adjacent property EXISTING WELL CONSTRUCTION DETAILS ❑ Open Bottom W Gravel Pack ❑ Uncased ❑ Other Well Log copy attached ❑ Yes rl'No Grout Seal ❑ No ❑ Yes ft below ground surface(bgs) Hole Diameter inches Well Conductor Casing❑ Yes IT'No Depth of Conductor Casing O ft bgs Diameter of Conductor Casing inches r, Well Casing Diameter__inches Total Depth,L(�ft Depthto Water ft Depth of Casing ft bgs P DESTRLTCTION SPECIFICATIO\' •I�C� Sealing Material from �__ft bgs to�_ft bgs Filler Material from�ft bgs to_eft bgs �^^,`� T Well casing to be perforated by one of the following methods: from ft bgs to ft bgs VC eD ❑ Mills Knife Number of cuts every ft and/or INQIP ❑ Explosives 13 Detonating cord ❑ with projectiles every ft ❑ without projectile Q q ❑ Detonating cord and boosters ❑ with projectiles every ft ❑ without projectile SAN `� 20/9 ❑ ocher YhAQU/ Sealin Cement(94 Ib bag/5-6 gal water) Sand Cement sack mix/7 gal water Bentonite d /RCNM COUN Bentonite(20%solid nufacturer Spec%solids_% Name Specs on File/ Spe�s Sub y EpARTT Place en o CP, Free Fall I Other mry �'ae.adP� !I'✓r l C A Seal Completion Complete wi h Mushroom Ca 1ft bgs Complete to Existing Surface Pad MFNT 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 TH CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION LA M IMUM D ANCE NOTICE REQUIRED FOR INSPEIOYS CONTRACTORS SIGNATURE TITLE C&AeR `3'1 DATE /-Y—/�' /4/cv i 2 G A AQ ENT USEONLY Application Accepied By Date Area Destruction Inspectiai By Date ployee ID# COMMENTS PE SC Received Chec Amount D to Permit/ Invoice# Well ID# Code Info as Rerm a Service Request# l 9 OU EHD 43-08 WELL DESTRUCTION PERMIT revised 4/14/18