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D WELL DESTRUCTION PERMIT .��"=� PUBLIC WATER SYSTEM ❑Yes Nib SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 600 E MAIN STREET-STOCKTON CA 95202-(209)468-3420 NON-REFUNDABLE PERMIT CALL 209 1953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED g JOB ADDRESS r / CITY/ZIP �ttp�--<� 5-�.3 r CROSS STREET £L D/h.A.�� N_ 193-- 070 -OZ— PARCEL SIZE fl- IIAND USE APPLICATION# _- OWNER PHONE OWNER ADDRESS CITY/STATE/ZIPp_f7 t1i� C.d -75/`/0 CONTRACTOR PHONE CONTRACTOR ADDV�rllllL —CITY/STATE/ZIP -�-� —_-v R��Ofyy C-57 WELL DRILLING LICENSE NUMBER -7 EXPIRATION DATE 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 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 ArCaved In ❑ Pit Well ❑ Inactive ❑ 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 ❑ 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 It bgs Diameter of Conductor Casing inches Well Casing Diameter inches Total Depth -4-1 ft Depth to Water ft Depth of Casing ft bgs rn DESTRUCTION SPECIFICATION Sealing Material from o2-I ft bgs to Sft 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 ft ❑ Without projectile rl ❑ Detonating cord and boosters ❑ With projectiles every ft ❑ without projectile ❑ Other Sealing Material . Neat Cement(94/b bag/S-6 gal water)_ Sand Cement &sack mix/7 gal water ,Bentonite Pellets Bentonite(20%solids) Manufacturer Spec%solids_% Name Specs on File Specs Submitted Placement Method - Pumped k Free Fall _. Other Seal Completion Y,,Complete with Mushroom Cap 0-4- —T ft bgs _ mplete o istin S cr Pad ta I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THEW RK WILL BE DONE IN ACC DANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS 1 CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT 1 AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION LAWS. M IM/UM24HO ADVANCE NOTICE REQUIRED FOR INSPECTIONS // 7 7 CONTRACTOR SIGNATURE r�_ TITLE 4fHDATE 7 -J �L 4 moo v`T e ls��t�� T J 7Fiy .TNT/ ewe!/To PAYMENT RECEIVED APR 2 3 2012 .,D.outh OCYJ11TY EHy a„hMEh"T� DEPARTMENT USE ONLY a Application Accepted By ate _ C Area Destruction Inspection By Date 3 Z Employee ID#_fC COMMENTS 44wcS S ,,.. , PE SC Received Amount D to Per IV Invoice# Well IDX Codes In B Remitted Service Re uest# 1741