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WELL DESTRUCTION PERMIT PUBLIC WATER SYSTEM ❑Yes ❑No f SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPT 1868 East Hazelton Avenue-STOCKTON CA 95205-6232 -(209)468-3420 NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED � y Joe ADDRESS /] 7 M CITY2IP n CROSS STREET Q. /Nr/t APN V / 6,6c)2-r—PARCEL SIZE n C� ND USE APPLICATION# o OWNER '- PHONE � /�� a ` m OWNER ADDRESS S CITY/STATE2C r IP / p/1 1.Q / J �6 a CONTRACTO PHONE 6 CONTRACTOR ADDRESS ! p CITY/STATE/ZIP f(A,}+�^��'h �7 WELL DRILLING LICENSE NUMBER ,-e7 C.,2 Q EXPIRATION DATE PERFORATION CONTRACTOR PHONE PERFORATION CONTRACTOR ADDRESS CITY/STATE2IP ❑ 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 fflrrnFttive ❑ 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 J- No Grout Seal ❑ No ❑ Yes ft below ground surface(bgs) Hole Diameter inches Well Conductor Casing❑ Yes ❑ No Depth of Conductor Casing ft bgs Diameter of Conductor Casing inches Well Casing Diameter inches Total Depth ft Depth to Water_ _�ft Depth of Casing _ft bgs DESTRUCTION SPECIFICATION Sealing Material from — _ft bgs to 4[ ft bgs Filler Material 6& LL A F-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 ft ❑ without projectile ❑ Detonating cord and boosters ❑ with projectiles every ft ❑ without projectile ❑ Other SeaIin�Material Neat Cement(94 lb bag 15-6 gal water) Sand Cement sack mix/7 gal water Bentonite Pellets r/Bentonite(20%solids) ,.,Manufacturer Spec%solids_% Name Specs or//�Ile Specs Submitted Placement Method ✓Pumped Free Fall ther 17,aA 6e,+-'e �4d Seal Completion Complete with Mushroom Cap_ ft bgs Complete to Existti -g Surface Pad I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINAN Ay, , AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS CURRENT AND ACTIVE WIT HE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT 1 AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION S. 1 O DVANCE NOTICE REQUIRED FOR INSP CTION p CONTRACTORS SIGNATURE TITLE S DATE _..- ....... L pAY � S Ro SEC �9F�r ?�19- _ ---- - - ....._i.._ i.- _ : : __..... .:_ y Ely RpQUUyCo U -. _ Ty�E MEN NT, ,_... ........... PgRT T�- --- -._ _ ....._..... NT DEPARTM ENT USE ONLY (l Application Accepted By `/ Date I I Z�/ I Area I � Destruction Inspection By Date y Employee I ,q COMMENTS PE SC Received Check#/ Amount Date Perm Invoice# Well ID# Codes Info By Remitted Service Re uest !tClS 1; I�I ' 0 � �1 EHD 43-08 WELL DESTRUCTION PERMIT revised 4/14/18