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WELL DESTRUCTION PERMIT L E COPY <br /> PUBIC`WATER SYSTEM ❑Yes <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 600 E MAIN STREET-STOCKTON CA 95202-(209)468.3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS F4PIRES1 YEAR FROM DATE ISSUED <br /> v, <br /> JOB ADDRESS eiGCAmp <br /> CCITY/ZIP ern <br /> CROSS STREET IS APN 1�� ��(--? PARCEL 2S _LAND S AP LICATI # b <br /> OWNER /� PHONE <br /> OWNER ADDRESS I 4:r CITY/STATE/Zi <br /> CONTRACTOR d PHONE D 3o <br /> cl <br /> CONTRACTOR ADDRESS V nn P✓ /� 331TCITY/STATE/LP P" v t" I <br /> C-57 WELL DRILLING LICt�)r6E NUMBER V EXPIRATION DATE_ �I O <br /> PERFORATION CONTRACTOR t4 OTA PHONE •.� <br /> PERFORATION CONTRACTOR ADDRESS Sawn e CITY/STAT ZP <br /> 11, C-57 Well Drilling License Number - /OO 71 Expiration Date V <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 Numberation Date <br /> REASON FOR DESTRUCTION O Dry ❑ Replace t Well ❑ Caved In [3Pit Well I;K Inactive 2 ❑ Test Hole <br /> Detected/Suspected Well Water Contaminants) <br /> Adjacent property with contamination(Address) <br /> Known Soil/Water contaminants at adjacentpro rty40) <br /> EXISTING WELL CONSTRUCTION DETAILS Open Bottom ❑ Gravel Pack ❑ Uncased ❑ Other <br /> Well Log copy attached ❑ Yes t-No Grout Seal ❑ No a Yes ft below ground surface(bgs) Hole Diameter inches <br /> Well Conductor Casing❑ Yes Qk No Depth of Conductor Casing ft bgs Diameter of Conductor Casing inches <br /> Well Casing Diameter inches Total Depth 110 ft Depth to Water� it Depth of Casing ft bgs <br /> DESTRUCTION SPECIFICATION <br /> Sealing Material from _ft bgs to_ _ft bgs 44"r Material from ft bgs to ft bgs <br /> Well casing to be erforated by one of the following methods: trom ft�gs to ft bgs <br /> Mills Knife _Number of cuts every and/or 4 0a /.kt <br /> ❑ Explosives❑ Detonating cord ❑ with projectiles every ❑ without projectile <br /> ❑ Detonating cord and boosters ❑ with projectiles every ft ❑ without projectile <br /> ❑ Other <br /> Sealing Materialeat Ceme (94 lb bag/5-6 gal water) Sand Cement sack mix/7 gal water Bentonite Pellets <br /> Bentonite(20%soli anufacturer Spec%solids_% Name Specs on File Specs Submitted <br /> Placement Method Pumped Free Fall Other <br /> Seal Completion Complele I us <br /> Cap �� ft bgs Complete to Existing 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 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 /> MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECT I NS /QT <br /> � <br /> CONTRACTORS SIGNATURE ` -1i'�� TITLE DATE f 1. `� 1 <br /> 4­4- <br /> 00 <br /> 06 <br /> 111 t..... y.. <br /> �_. <br /> �l L <br /> DEPARTMENT USE ONLY <br /> Application Accepted B Date � q Area <br /> Destruction Inspection Date �,In,1�q Employee ID# <br /> COMMENTS <br /> y C5 <br /> PESC Received Check#/ Amount D Perm"' Invoice# Well ID# �t <br /> Codes Info B Cash Remitted Service Request# <br /> 11B! A*—WMftkom <br /> EHO 43-08 -FILTEPERICO P Y <br /> 10/5/07 <br />