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WELL DESTRUCTION PERMITPUBLICwATERsYSTEM Ores ONO 3 600 E MAIN STREET-STOCKTON CA 98202-(209)468-3420 SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENTCALL 209 953-7697 FOR INSPECTIONS EXPIRES 7 YEAR FROM DATE ISSUED 1 NON-REFUNDABLE PERMIT QgH 7 ( `-� ld !i �----CITY21P C� �n JOS ADDRESS � ��1 n r� o S APN I'J 1S PARCEL SIZEJ-JILAND USE APPLICATION# CROSSS EET�� r PHONE h DINNERd CA 170 £ CITY/STATE/LP Q OWNER ADDRESS HONE CONTRACTOR .. �-L - C L � C CONTRACTOR ADDRESS ITYISTATE21P G '1'1 EXPIRATION DATE C-57 WELL DRILLING LICENSE NUNBER eli- PHONE PERFORATION CONTRACTOR CIPr/STATE/ZIP PERFORATION CONTRACTOR ADDRESS Expiration Date i License Number ❑ C-57 Well Drilling .Expiration Date ❑ Bureau of Alcohol,Tobacco and Firearms-Users of High Explosives License Number Expiration Date License Number � ❑ CHP Hazardous Matelal Transportation for Explosives Expiration Date i ❑ San Joaquin County Sheriff-Coroner Explosives Application and Permit License Number iration Date ❑ California Occupational Safety Health-Blaster License Number ExpRr:ecoN FOR DESTRUCTION ❑ Dry Replacement Well ❑ Caved In ❑ Pit Well ❑ Inactive ❑ Test Hole Detected/Suspected Well Water Contaminant(s) Adjacent property With contamination(Address) Known Soil/Water contaminants at adjacent property EXISTNG WELL CONSTRUCTION DETAILS Yh Open Bottom /''ravel Pack ❑ Uncased ❑ Other No Grout Seal 13No —❑„Yes ft below ground surface(bgs) Hole Diameter Inches Well Log copy attached 13 Yes Diameter of Conductor Casing inches Well Conductor Casing❑ Yes Depth of Conductor Casing ft bgs Well Casing Dlametor$,_inches Total Depth 1.LO It Depth to Water�A ft Depth of Casing ft bgs DESTRUCTION SPECIFICATION Sealing Material from ft bgs to ft bgs Filler Material from It bgs to ft bgs Well casing to be oerforated 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 I ❑ Detonating cord and boosters ❑ With projectiles everyft ❑ without projectile j ❑ Other ` Seaiing Material ❑ Neat Cement(g4/b bag/5 6 ga!water)❑ Sand Cement sack mix17 gal water X Bentonite Pellets _i] 8errtonite(211%soilds) ❑ Manufacturer Spec%solids_% Name ry ❑ Specs on File ❑ Specs Submitted acement Method'0 P'umped”"—'� "FrdB""Fall' "�OOtrier'^-- '` '` — Pl Seal Completion KComplete with Mushroom Cap ft bgs 0 Complete to Existing Surface Pad 1 HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS CURRENT AND ACTWE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT 1 AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION LAWS. MINIMUM f2244�HjO�U/R�AiDVVANCE NOTICE REQUIRED F05IrNSPECTIONS CONTRACTORS SIGNATURE I-U /'/"L�v!'�/G7/Y _ __ TITLE ,A I I I.eli DATE. +++i I Lam" ECEIY.ED_ i I I �.. ._L01 - �- JOADUI .COON_ DEPART RVIRDf#A '�L _Ha - - - � - - - i 4- En:'T-M E-N It-WS-E--ON JAL Application Accepted Date Area _ Destruction Inspection By-Z Date 1 Employee IID#:: _ COMMENTS'Lf— �/c/�L��/t i ?t'�l 70 moi' rJ�✓1 �" lob !C/-f��rr�+ C!/y� (t,�'Z�,llS�i T�% F� ?H��fZG•To G��/,✓�r'.�?.s��a%�.,�L��G:.G��7/_!- 7co.� PE Sc Received CherJd#" Amount Date Permly Invoice# Well ID# Codes Info sh Remitted Service Request# I161 24b 9 ' I EHD 43-08 WELL DESTRUCTION PERMIT 10/5107