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WELL DESTRUCTION PERMIT h PUBLIC WATER SYSTEM ❑Yes ❑No 4 SAN JOAQUIN 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 F OM DATE ISSUED ' '/ rn JOB ADDRESS Z3 W S -7 CITY/ZIP CROSS STREET APN v PARCEL SIZ J FLS LAND USE APPLICATION# _ OWNERz PHONE r r OWNER ADDRESS — CITY/STATE/ZIP CONTRACTOR PHONE 3'27312,0 CONTRACTOR CONTRACTOR ADDRESS D `G CITY/STATE/ZIP Gam/ elf e -C-57 WELL DRILLING LICENSE NUMBER EXPIRATION DATE 007,e- 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 g Inactive ❑ Test Hole Detected/Suspected Well Water Contaminant(s) Adjacent property with contamination(Address) Known Soil/Water contaminants at adjacent property--- EXISTING roperty _EXISTING WELL CONSTRUCTION DETAILS ❑ Open Bottom ❑ Gravel Pack ❑ Uncased ❑ Other Well Log copy attached ❑ Yes ❑ No Grout Seal ❑ No ❑ Yes___ ft below ground surface(bgs) Hole Diameter inches Well Conductor Casing ❑ Yes ❑ No Depth of Conductor Casing __ ft bgs Diameter of Conductor Casing inches Well Casing Diameter /If_____inches Total Depth _? _ _ It Depth to Water ZD _ ft Depth of Casing _ It bgs DESTRUCTION SPECIFICATION /I / Sealing Material from � ' ft bgs to . It bgs Filler Material __ _ _ from ft bgs to ft bgs Well casing to be perforated by one of the following methods: from ft bgs to ft bgs Mills Knife �Nurnber of cuts every_3_7_5 ft and/or _ Explosives ❑ Detonating cord ❑ with projectiles every ft ❑ without projectile ❑ Detonating cord and boosters ❑ with projectiles every _ ft ❑ without projectile ❑ Other Sealing Material Neat Cement(94 lb bag/5-6 gal water) Sand Cement /b'. S sack mixll gal water `Bentonite Pellets Bentonite(20%solids) Manufacturer Spec%solids % Name Specs on File Specs Submitted Placement Method Pumped Free Fall Other Seal Completion Complete with Mushroom Cap 3_s' It 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. MINI UM HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS CONTRACTORS SIGNATURE TITLE Q,5;�7- DATE Z- ............................... �.. j �F M� _ a lg AI 2010 _...... ,/ AQU/N lRO/y COU/y i i ....... -_._i-....... ........_........._......_......_.._..._.....-._...._._...._._..........._......... _._-.y...-..._ -_.__._. ._..__....._ ..... r I � i t 1 i PARTMENT USE ON Y i Application Accepted By Date a" l Area _ Destruction Inspection By /t/ �E�GLL,, f�Date `'/ Employee ID# COMMENTS PE SC Received Check#/ Amount Permit/ods Info B Cash Remitte Date Service Request# Invoice# Well ID# 6s' IIIIIIIII - D EHD 43-08 WELL DESTRUCTION PERMIT 4/30/12