WP0040558 - Laserfiche WebLink

Home Browse Search

WELL DESTRUCTION PERMIT PUBLIC WATER SYSTEM /Yes ❑No ` SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 East Hazelton Avenue-STOCKTON CA 95205 - (209)468-3420 NON-REFUNDABLE PERMIT /1CArLL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS I f QS i'A <1 CITY/ZIP Is - 004, C4S O CROSS STREET Al P-4 s APN I S /,3-DO / PARCEL SIZE2-?A�.AND USE APPLICATION# V OWNER �Q PHONE 4 m OWNER ADDRESS /•-CD n CITY/STATE2 �� 1P e `JO"�'t CONTRACTOR (!J /////I vv��n 4- PHONE - /kG / 2 CONTRACTOR ADDRESS ��/a, J//C F CITY/STATE/ZIP _F6t/e A—C-57 WELL DRILLING LICENSE NUMBER Z/3 —EXPIRATIONDATE ��'�7 -2,1 � PERFORATION CONTRACTOR PHONEA /16 9j7/d/ �A / �7 PERFORATION CONTRACTOR ADDRE . RJm)( /3�0 (A P/A CITY/STATE/ZIP 0 C�. / 76 Eir-' C-57 Well Drilling License Number 6/ �?41.2 / JP Expiration Dater cP/-21 0D/Bureau of Alcohol,Tobacco and Firearms-Users of High Explosives License Number 9-CIY//3^3.3•6^Expiration Date/2 '1 2 0 Pi- CHP Hazardous Material Transportation for Explosives License Number/'?71;/;7 Expiration Date 7-3/ 'ei �? 2- Sari Joaquin County Sheriff-Coroner Explosives Application and Permit License Number 3 Expiration Date/©-e-- 2 ❑ California Occupational Safety Health-Blaster License Number /b`//G:, Expiration Date 23--2--T REASON FOR DESTRUCTION ❑ Dry ❑ Replacement Well E4,,Caved In ❑ Pit Well ®--tractive ❑ Test Hole 1 Detected/Suspected Well Water Contaminant(s) Adjacent property with contamination(Address) Known Soil/Water contaminants at adjacent property EXISTING WELL CONSTRUCTION DETAILS ❑ Open Bottom P- Uravel 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 ❑ No Depth of Conductor Casing ft bgs Diameter of Conductor Casing _ inches Well Casing Diameter _ I _ inches Total Depth I 6 R Depth to Water -_yam_ ft Depth of Casing _ l�G it bgs DESTRUCTION SPECIFICATION Sealing Material from it bgs to 820 it bgs Filler Material��ht oeocj!e from/ft--ft bgs to C,�, it bgs Well casing to be perforated by one of the following methods: _ from_ it bgs to____ _ it bgs ❑ Mills Knife __ _ ___._ Number of cuts every____...__..__.. 2_____._ft and/or 7O3 _ _ D R- Explosives etonating cord ❑ with projectiles every /b it ❑ without projectile & .Js fir'f// Da nating cord and boosters ❑ with rojectile every it ❑ without projectile C�/0 N n l�Other f/ 1}Q s•' �'l'L�� Sealing Material Neat Cement( Ib bag/5-6 gal water))( Sand Cem t d• �? ______sack mix/7 gal water Bentonite Pellets Bentonite(20%solids) Manufacturer Spec%solids % Name Specs on File Specs Submitted Placement Method a� Pumped Free Fall F] Other PAYM- E \ Seal Completion Complete with Mushroom Cap - _ it bgs 44;�lete to Existing Surface PaREC EIVEn 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 RE©I�t ,c IS CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE� ALL WORKERS COMPENSATION LAWS. SAN JOAQUIN COUNTY IMUM�4 HOU ADVANCE NOTICE REQUIRED FOR INSPECTIO S MEAL HRONMENTAL DEPARTMENT CONTRACTORS SIGNATURE TITL Y r DATE Z- �/ _ 2fl ! tu (l v Destci o�( - 1 .. .- --_._.._�. I__.._._-._..._.. ..... ..........._- -....._.-.. ..._ 4 - - . ---- - � e J _.. _. A- -54 ...... . __..... .._ (�... _.... __._.._.. ...... ! 1 ' t 11 i f. p DE A R T M E N T USE O LY Application Accepted By /�/ f Date / _ Area Destruction Inspection By Date 7 ) Employee ID# COMMENTS 4- S PE Sc Received a #/ Amount Permit/ Codes Info Cash Remitted Date Service Re ues 05Invoice# Well ID# l 6 0! EHD 43-08 WELL DESTRUC LION PERMIT 4/30/12