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PUBLIC WATER SYSTEM❑Yes M No <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 600 E MAIN STREET-STOCKTON CA 95202-(209)4663420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JoeAOOREss /0,140A1C.. Aw. CmZp VED <br /> CROSS STREET Bear Creek APN 08402001 PARCEL SIZE-LAND LANG USE APPLICATION <br /> OWNER � � qq ? PHONE w <br /> OWNER ADDRESS_ I I,(,[ 1 I\�C.. • 1.A:1 \ iii 1 CITY/STATEZP O <br /> 11 <br /> CONTRACTOR Precision Sampling,Inc. PHONE 209-465-8712 <br /> CONTRACTOR ADDRESS 2365 Wigwam Dr. CITY/STATEMP Stockton,CA 95205 \ ry�� <br /> C-57 WELL DRILLING LICENSE NUMBER 636387 ExPIRATION DATE 0 113 1/20 1 2 A f7 <br /> PERFORATION CONTRACTOR NA PHONE S <br /> PERFORATION CONTRACTOR ADDRESS CITY/STATE/LP [� <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) Ar <br /> Adjacent property with contamination(Address) <br /> Known Soil/Water contaminants at adjacent property4419& 1 <br /> EXISTING WELL CONSTRUCTION DETAILS Cl Open Bottom Gravel Pack ❑ Uncased ❑ Other <br /> Well Log copy attached ❑ Yes ANo Grout Seal ❑ No A Yes.31_5 ft below round surface g <br /> g (bgs) Hole Diameter inches <br /> Well Conductor Casing❑ Yes M No Depth of Conductor Casing R bgs Diameter of Conductor Casing inches <br /> Well Casing Diameter 22 inches Total Depth- S ft Depth to Water. It Depth of Casing ft bgs 1 <br /> DESTRUCTION SPECIFICATION IG <br /> Sealing Material from ft bgs to &0 ft bgs Filler Material 9�� from 0 ft bgs to'&� ftbgs <br /> Well casing to be perforated by one of the following methods: from ft bgs to R bgs <br /> ❑ Mills Knife Number of cuts every ft and/or <br /> ❑ Explosives❑ Detonating cord ❑ with projectiles every it ❑ without projectile <br /> ❑ Detonating card and boosters ❑ with projectiles every ft ❑ without projectile <br /> ❑ Other <br /> Sealing Material Neat Cement(94 Ib bag/5.6 gal water) Sand Came ix/7 gal water Bentonite Pelle <br /> Bentonite(20%solids) Manufacturer Spec%soli 9y Name Specs on File <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 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 /> MIN HOUR ADVANCE NOTICE REQUIRED FOR NSPECTIONS <br /> CONTRACTORS SIGNATURE TITLE DATE�� <br /> /A„/ <br /> G . 38.Ogb <br /> ko - <br /> !o,/do ,x041--" -Q.- <br /> V/V <br /> D TMENT USE O <br /> Application Accepted By 1 A Date1 Area <br /> L <br /> Destruction Inspectio y Date Employee ID#- <br /> COMMENTS <br /> PE SC Received heck#/ Amount Date Perrnitl Invoice# Well ID# <br /> Codes InfoAy Ca Remitted I I Aiervice Re uest# <br /> d Z w If <br /> EHO 43-OB - WELL DESTRUCTION PERMIT <br /> 1015/07 <br />