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/l/+e'1 <br /> F "ELL DESTRUCTION PERMI� <br /> PUBLIC WATER SYSTEM ❑Yes [:]No <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE 3"n FL-STOCKTON CA 95202 (209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL(209)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> Qj t. ci6rn <br /> JOB ADDRESSCIA <br /> �J CITY/ZIP M <br /> CROSS ET APN /' '- PARCEL SIZE AND US//E APPLICATION# o <br /> OWNER PHONE 6 "aC4 L m <br /> OWNER ADDRS CITY/STATE/ZIP' <br /> CONTRACTOR CJ J( PHONE <br /> CONTRACTOR ADDRESS I CITY/STATE/ZIP (LJ'� q(3a(.- <br /> 1 C-57 WELL DRILLING LICENSENUMBERZJ (�b � EXPIRATION DATE '�� -OR, <br /> PERFORATION CONTRACTOR � 0 �J'e 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 Inactive ❑ 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 Ex No Grout Seal ❑ No ❑ Yes ft below ground surface(bgs) Hole Diameter inches <br /> Well Conductor Casing ❑ Ye ❑ No Depth of Conductor�Caa 1 9 ft b1gj ., Diameter of Conductor Casing inches C <br /> Well Casing Diameter_inches Total Depth M �`' Depth to Wate T- 2,'1 ft Depth of Casing ft bis <br /> DESTRUCTION SPECIFICATION <br /> Sealing Material from bgs to IeO ft bgs Filler Material �i/�la'L/from ft bgs to ft bgs <br /> Well casing to be perforated by one of the followine methods: fromaftt bgs to ft 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 /> Sealing Material ❑ Neat Cement(94/b bag/5-6 gal water) Sand Cement sack mix/7 gal water ❑ Bentonite Pellets <br /> ❑ Bentonite(20%solids) ❑ Manufacturer Spec%solids Y, % Name ❑ Specs on File ❑ Specs Submitted <br /> Placement Method ❑ Pumped ❑ Free Fall Other <br /> Seal Completion ❑ Complete with Mushroom Cap ft bgs Complete to Existing Surface Pad <br /> 1 HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. 1 ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA-CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> MINIMU Jy24 H R DVANCE NOTICE REQUIRED FOR I ISPECTIONS <br /> CONTRACTORS SIGNATURE- %(i r// " TITLE DATE <br /> i <br /> E P M NT USE ONLY <br /> Application Accepted B Date Area <br /> Destruction Inspection By DateIg1 �7 <br /> COMMENTS <br /> YO <br /> PE SC Received Chec Amount Permit/ NM <br /> Codes Info B ash Remitted Date Service Request# I1 { EPA TMEINWell ID# <br /> X33LJ <br /> CA <br /> EHD 43-02.008 Well Destruction Permit <br /> 1/2712005 <br />