SU0012489 - Laserfiche WebLink

Home Browse Search

WELL DESTRUCTION PERMIT PUBLIC WATER SYSTEM ❑Yes ❑No SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 600 E MAIN STREET-STOCKTON CA 95202 - (209)466-3420 NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS S / CITYfZIP / G/ +� vi CROSS STREET C.�.�[,}� APN lq3 /PARCEL SIZE_LAND USE APPLIC TION#_ c OWNER T PHONE r OWNERADDRESS l/ .5 / �"�/;l///1 CITY/STATE/ZIP Pe- CONTRACTOR [�'eEr «FF PHONE CONTRACTOR ADDRESS 0 /?L,,< --I LZ CIN/STATEIZIP 19.3, S C-57 WELL DRILLING LICENSE NUMBER 3 r. EXPIRATION DATE ! I 3 PERFORATION CONTRACTOR PHONE PERFORATION CONTRACTOR ADDRESS CITY/STATE/ZIP ❑ C-57 Well Drilling License Number Expirabon 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 Sc,%Vater contaminants at adjacent property____ EXISTING WELL CONSTRUCTION DETAILS ❑ Open Bottom ❑ Gravel Pack ❑ Uncased ❑ Other Well Log copy attached : Yes ❑ 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 0_ ft bgs to_../L ft 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 ft ❑ without projectile ❑ Other Sealing Material - Neat Cement(94/b bag/5-6 gal water)-- Sand Cement sack mix/7 gal water .0 Bentonite Pellets Bentonite(20Y solids) Manufacturer Spec%solids_% Name Specs on File Specs Submitted Placement Method Pumped Free Fall - Other Seal Completion k Complete with Mushroom Cap ft gs Comple 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. M IMUM 24 UR ADVANCE NOTICE REQUIRED FOR INSPECTIONS T� C _ CONTRACTORS SIGNATURE TITLE Pw' 9 DATE ` PAYMENT RECEIVr�'' L.Je1/ MAY 9 2012r S?4 I E A MENT USE ONL Application Accepted By Date i Area Destruction Inspection By - Date ��1�— _ Employee ID#_ COMMENTS PE SC Received Chec Amount PermiU Codes Info B Service Cash emitted i Date Re uest# Invoice# Well ID# hl 7 z o