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1 WELL DESTRUCTION PERMIT PUBLIC WATER SYSTEM ❑Yes ❑No SAN JOAQUIN COUNTY ENNRoNNENfAL HEALTH DEPT 1868 East Hazelton Avenue-STOCKTON CA 95205-6232-(209)468-3420 NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED PA 3� JOB ADDRESS c'rl;A LY1 CITY/ZJP S Mooty.4 , ,� CROSS STREET C V A`PN 0`QS 5/1 k 0 15 PARCEL SIZE•a�I LAND USE APPLICATION# e OWNER &l'nQ,S1S Cq1 /F- SA ApTC. L!SUV 10 PHONE OWNER ADDRESS SA MI t°`^�5 a 6OVl.- CITY/STATEILP C,, bGI'� a�rl �C A L159 CONTRACTOR \I n��P t��f 11 \��9 PHONE ala Ll-; �-7 CONTRACTOR ADDRESS CITYISTATEMP C-57 WELL DRILLING LICENSE NUMBER-231393 EXPIRATION DATE-7—31— 220 PERFORATION CONTRACTOR PHONE PERFORATION CONTRACTOR ADDRESS CITY/STATE/LP O 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 14 Open Bottom ❑ Gravel Pack ❑ Uncased ❑ Other _ Well Log copy attached ❑ Yes V� No Grout Seal ❑ Nu ❑ Yes__ ft below ground surface(bgs) Hole Diameter inches Well Conductor Casing❑ Yes 4 No Depth of Conductor Casing _ft bgs Diameter of Conductor Casing inches Well Casing Diameter___inches Total Depth �)�> ft Depth to Water '�'40_If Depth of Casing ft bgs DESTRUCTION SPECIFICATION � Sealing Material from 55 ft bgs to ft bgs Filler Material-+��J�T'� from It bgs to ft bg Well casing to be perforated by one of the following methods: from It bgs to ft bgs �/t ❑ Mills Knife Number of cuts every ft and/or 0 /�/� N r ❑ Explosives❑ Detonating cord ❑ With projectiles every ft ❑ Without projectile C/�I ft 1 ,� 1 ❑ Detonating cord and boosters ❑ with projectiles every ❑ without projectile ` �/ D ❑ Other Sealing Material )'Neat Cement(94 Ib bag 15-6 gal water) Sand Cement - sack mix/7 gal water Bentonite PelM q o[� Bentonite(20%solids) Manufacturer Spec%solids_% Name Specs on File SpecsSubmitted U ?0?0 Placement Method Pumped Free Fall Other AN J Seal Completion Complete with Mushroom Cap_ It bgs x Complete to Existing Surface Pad EN, VIN COU JOAQU NY CERTIFY THAT I COUNTY ORDINANCES, STATE LAWS ED THIS AND RULES A AION NDND THAT THE REGULATIONS.NIORK A SO ILL BE CERTIFYDONE IN THAT MYCREQUIREDEI CENSE IS PART41ENT CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION LAWS. M&Mfiffl 48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS _ CONTRACTORS SIGNATURE TITLE V I C'C r?f t h tATIE C �^► —�—e X `--� VC DEPARTMENT USE ONLY Application Accepted By Date Area Destruction Inspection ByDate Employee I _ COMMENTS — A U A 1TYlY PE SC Received Ch Amount Date Permit! Invoice# Well ID# Codes Info as Remitted rvice RequestAL EHD 43.08 WELL DESTRUCTION PERMIT revised 4/14/18