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WELL DESTRUCTION PERMIT <br /> PUBLIC WATER SYSTEM ❑Yes ❑No <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPT 1868 East Hazelton Avenue-STOCKTON CA 95205-6232-(209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> • I <br /> JOB ADDRESS 7 • /Vl A. I CITY/ZIP , , <br /> D. /M//* APN O` PARCEL SIZE > <br /> CROSS STREET ND USE APPLICATION# C <br /> fA � <br /> QWNER •- � � PHONE 3 50!Z40/7� L} <br /> OWNER ADDRESS CITYISTATE/ZIP ��AO/1 `.4 / <br /> CONTRACTO PHONE <br /> VWCONTRACTOR ADDRESS CITY/STATE/zIPq(�(� r <br /> I,a-o7 WELL DRILLING LICENSE NUMBER V 7 2 EXPIRATION DATE J�J 2, <br /> PERFORATION CONTRACTOR PHONE <br /> PERFORATION CONTRACTOR ADDRESS CITY/STATE/ZIP <br /> ❑ C-57 Well Drilling License Number Expiration Date <br /> Bureau of Alcohol,Tobacco and Firearms-Users of High Explosives License Number Expiration Date <br /> CHP Hazardous Material Transportation for Explosives License Number Expiration Date <br /> San Joaquin County Sheriff-Coroner Explosives Application and Permit License Number Expiration Date <br /> California Occupational Safety Health-Blaster License Number Expiration Date <br /> REASON FOR DESTRUCTION ❑ Dry ❑ Replacement Well ❑ Caved In ❑ Pit Well ArMIRfive ❑ Test Hole <br /> Detected/Suspected Well Water Contaminant(s) <br /> Adjacent property with contamination(Address) <br /> Known Soil/Water contaminants at adjacent property <br /> EXISTING WELL CONSTRUCTION DETAILS/ ❑ Open Bottom ❑ Gravel Pack ❑ Uncased ❑ Other <br /> Well Log copy attached ❑ Yes g No Grout Seal ❑ No ❑ Yes ft below ground surface(bgs) Hole Diameter inches <br /> Well Conductor Casing❑ Yes ❑ No Depth of Conductor Casing It bgs Diameter of Conductor Casing inches <br /> Well Casing Diameter inches Total Depth�_ft Depth to Water ft Depth of Casing _ft bgs <br /> DESTRUCTION'SPECIFICATION /�'++ <br /> Sealing Material from n bgs to-�.[> ft bgs Filler Material 94am w l from ft bgs to ft bgs <br /> Well casing to be perforated by one of the following methods: from ft bgs to It bgs <br /> ❑ Mills Knife Number of cuts every ft and/or <br /> ❑ Explosives❑ Detonating cord ❑ with projectiles every ft ❑ without projectile <br /> ❑ Detonating cord and boosters ❑ with projectiles every ft ❑ without projectile <br /> ❑ Other <br /> Sealink Material Neat Cement(941b bag/5-6 gal water) Sand Cement sack mix/7 gal water Bentonite Pellets <br /> : Bentonite(20%solids) - (Manufacturer Spec%solids % Name Specs o�JFile Specs Submitted <br /> Placement Method ✓Pumped Free Fall ther A�,( if Aes, 0 d Ad <br /> Seal Completion Complete with Mushroom Cap ft bgs "Complete to Existi g Surface Pad <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> JOAQUIN COUNTY ORDINAN STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT AND ACTIVE WIT HE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION S. <br /> I O DVANCE NOTICE REQUIRED FOR INSPCTpION� p /p <br /> CONTRACTORS SIGNATURE TITLE J ''✓✓tt--DATE -7•'Z�J /7 <br /> RFCE FNT <br /> IDRI`vt w.s a� .[Vol <br /> PA <br /> Jt1L <br /> Ja 20' <br /> __- <br /> �DA <br /> , E 3 <br /> NviR N c <br /> .;........;... 1 4 H TH U�FNrU 71' <br /> i <br /> EPgRTM N <br /> AA <br /> DEPARTMENT USE ON Y <br /> Application Accepted By Date Area <br /> Destruction Inspection By Date Employee I <br /> COMMENTS LA � + ��� " P <br /> PE SC Received Check#/ Amount Permit/ <br /> Codes of B emitted Date ervice Request Invoice# Well ID# <br /> O <br /> EHD 43-08 WELL DESTRUCTION PERMIT <br /> revised 4/14/18 <br />