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WELL DESTRUCTION PERMIT PUBLIC WATER SYSTEM ❑Yes ❑No SAN JOAOUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 East Hazelton Avenue-STOCKTON CA 95205 - (209)468-3420 NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED /J 1-0', qr r JOB ADDRESS u)/4 el- 64o A CITY/ZIP S�CC/� /O/t CROSS STREET 0-6e PN Q d�/'I D?? D�Q PARCEL SIZE .�I LAND USE APPLICATION# OWNER6AL-g A f/ i A e mC �A ��DR/'.ICS �-//G PHONE OWNER ADDRESS E CITY/STATE/ZIPY 7b e JAQol C'A 9X21,5_ CONTRACTOR ,4 w / 2 / I r/1 Q PHONE O �^ G CONTRACTOR ADDRESS 3 0 0 r l CITY/STATE/ZIP 7--r-e p C-57 WELL DRILLING LICENSE NUMBER 21,? EXPIRATION DATE) PERFORATION CONTRACTOR PHONE PERFORATION CONTRACTOR ADDRESS CITY/STATE/ZIP ❑ C-57 Well Drilling License Number Expiration Date ❑ Bureau of Alcohol,Tobacco and Firearms-Users of High Explosives License Number Expiration Date ❑ CHP Hazardous Material Transportation for Explosives License Number Expiration Date ❑ San Joaquin County Sheriff-Coroner Explosives Application and Permit License Number Expiration Date ❑ California Occupational Safety Health-Blaster License Number Expiration Date REASON 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__ EXISTING WELL CONSTRUCTION DETAILS ❑ Open Bottom ❑ Gravel Pack ❑ Uncased ❑ Other Well Log copy attached ❑ Yes F"'No Grout Seal ❑ No ❑ Yes __ __ It below ground surface(bgs) Hole Diameter _ inches Well Conductor Casing ❑ Yes IT"'No Depth of Conductor Casing __ ft bgs Diameter of Conductor Casing inches Well Casing Diameter 2 inches Total Depth 7 It Depth to Water------It Depth of Casing It bgs DESTRUCTION SPECIFICATION Sealing Material from _ -ft bgs to ft bgs Filler Material from ft bgs to ft bgs Well casing to be perforated by one of the following methods: _ _ ___from It bgs to ft bgs ❑ Mills Knife _---_----Number of cuts every It and/or ❑ Explosives ❑ Detonating cord ❑ with projectiles every ft ❑ without projectile ❑ Detonating cord and boosters ❑ with projectiles every _ It ❑ without projectile ❑ Other Sealing Material Neat Cement(94 lb bag/5-6 gal water) Sand Cement sack mix17 gal water Bentonite Pellets Bentonite(20%solids) Manufacturer Spec%solids __% Name _ Specs on File Specs Submitted Placement Method Pumped Free Fall F1 Other Seal Completion Complete with Mushroom Cap ft bgs Complete to Existing Surface Pad I 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 ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION LAWS. ys INIMUM H UR ADVANCE NOTICE REQUIRED FOR INSPECTIONS /� CONTRACTORS SIGNATURE TITLE�&h��'1'S6 DATE /Z -6,-Z-7 E -_ . t - It - - -_ i _. ..... �_. - T o }�Iann _ _. ._<_..._.. _. _... _ -. .. _ . ... _.. _. _. e .... .....-. .....- j i v SAN : , E � ' f _ _._...........-........................__....;...........f._ ! .. � W M AQUIIV hl ry p NMENTAL 7y ARTENT USE N L Application Accepted By Date Area Destruction Inspection By Date I v2y J,69 Employee ID# COMMENTSLlAJ }1 S /�1�L� �7�1�1/� ��r— IsT�I��✓ l14 —PA 2 L/VOJa 46 b PE Sc Received heck# Amount Permit/ Codes Info B Cash emitted Date Service Re uest# Invoice# Well ID# 02 5 C 4 30/12 OS CWe`/ P&Y-ell- 0 Ll' .Il� w�T� �pV2L rp �,� � _ �j� LL DESTRUCTION PERMIT