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WELL DESTRUCTION PERMIT 1 <br /> PUBLIC WATER SYSTEM [1 Ye>�L E COPY <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 EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS /O 2,00 �4t.. CITY/ZIP <br /> m <br /> Bear Creek 08402001 2.7 <br /> Y <br /> CROSS STREET Bear <br /> APN PARCEL SIZE_LAND USE APPLICATION# <br /> Cc <br /> OWNER PHONE A <br /> y <br /> OWNERADDRESS U " MUCK �I CITY/STATE/ZIP <br /> CONTRACTOR Precision Sampling,Inc. PHONE 209-465-8712 <br /> \ <br /> CONTRACTOR ADDRESS 2365 Wigwam Dr. CITY/STATE/ZIP Stockton,CA 95205 �\ <br /> C-57 WELL DRILLING LICENSE NUMBER 636387 ExPIRATION DATE 01/31/2012 <br /> PERFORATION CONTRACTOR NA 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) 0 <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 *No Grout Seal ❑ No ), Yes.7I.S ft below ground surface(bgs) Hole Diameter 8 inches <br /> Well Conductor Casing❑ Yes In No Depth of Conductor Casing ft bgs Diameter of Conductor Casing inches <br /> Well Casing Diameter 2 inches Total Depth,56,5- ft Depth to Water ft Depth of Casing ft bgs �^y, <br /> DESTRUCTION SPECIFICATION \" <br /> Sealing Material from Q ft bgs to��ft bgs Filler Material ' n' from 0 ft bgs to 19D bgs <br /> Well casing to be perforated by one of the following methods: from ft 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 lb bag/5-6 gal water) Sand Cemen ix/7 gal water BentoDPelle <br /> Bentonite(20%solids) Manufacturer Spec%soli /n NameSpecs on File <br /> Placement Method Pumped Free Fall Other , <br /> Seal Completion Complete with Mushroom Cap It 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. I 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 /> MINff HOUR ADVANCE NOTICE REQUIRED FOR NSPECTIONS <br /> CONTRACTORS SIGNATURE TITLE DATE <br /> ko <br /> .�-�- <br /> AViV <br /> DART ENT USE 0 <br /> 9 i <br /> Application Accepted By Date—w/" �r Area <br /> Destruction Inspectio Date D# <br /> COMMENTS <br /> PE SC Received heck#/ Amount Date PermlU Invoice# Well ID# <br /> Codes Info Ca Remitted Service Request# <br /> EHD 43-08 WELL DESTHL <br /> C 0 P Y <br /> 10/5/07 <br />