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WELL DESTRUCTION PERMIT <br /> s <br /> PUBLIC WATER SYSTEM ❑Yes ❑No <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPT 1868 East Hazelton Avenue-STOCKTON CA 95205.6232 -(209)468-3420 <br /> NON-REFUNDABLE PERMIT L(2019',953-7697 FOR INSPcc-: s a PIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS SO G! O CITY21P J'T C/4y <br /> y <br /> Q M <br /> CROSS STEET !�� yyaK ta! Na y i • ;2(y 'a O C/ PARCEL SizrC LAND USE APPLICATION# <br /> ne o <br /> OWNER SJi, 4 1• (t�J /! PHONE 7c �J - 2.0 3 tA.f <br /> OWNER ADDRESS 7 IR L G CITY/STATE/ZIP a Y <br /> CONTRACTOR r J 4 pU <br /> L PHONE ` L <br /> CONTRACTOR <br /> __ADDRESS G CITYISTATE2IP <br /> `` <br /> c+77LWELL DRILLING LICENSE NUMBER �.�a'�` ) EXPIRATION DATE <br /> PERFORATION CONTRACTOR PHONE <br /> PERFORATION CONTRACTOR ADDRESS CITYISTATE/ZIP <br /> ❑ C-57 Well Drilling License Number Expiration Date <br /> Bureau of Alcohol,Tobacco and Firearms-Users of High Explosives License Number Expiration Date <br /> CHP Hazardous Material Transportation for Explosives License Number Expiration Date <br /> San Joaquin County Sheriff-Coroner Explosives Application and Permit License Number Expiration Date <br /> California Occupational Safety Health-Blaster License Number Expiration Date <br /> REASON FOR DESTRUCTION ❑ Dry ❑ Replacement Well ❑ Caved In ❑ Pit Well Q.kreCfive ❑ Test Hole <br /> Detected/Suspected Well Water Contaminant(s) i <br /> Adjacent property with contamination(Address) <br /> Known Soil/Water contaminants at adjacent property- <br /> EXISTING WELL CONSTRUCTION DETAILS ❑ Open Bottom ❑ Gravel Pack ❑ Uncased ❑ Other f <br /> Well Log copy attached ❑ Yes ❑ No Grout Seal ❑ No ❑ Yes ft below ground surface(bgs) Hole Diameter inches <br /> Well Conductor Casing❑ Yes ❑ No Depth of Conductor Casing ft bgs Diameter of Conductor Casing inches <br /> Well Casing Diameter <F inches Total Depth—�ft Depth to Water�ft Depth of Casing cP0 ft bgs <br /> DESTRUCTION SPECIFICATION <br /> Sealing Material from CIRD ft bgs to_4�1 ftbgs Filler Materia: �:�3n from TO bgs to ft bgs <br /> Well casing to be perforated by one of the following methods: <br /> from ft bgs to ft bgs <br /> ❑ Mills Knife Number of cuts every ft and/or <br /> ❑ Explosives❑ Detonating cord ❑ with projectiles every ft ❑ without projectile <br /> ❑ eibnatinq�*rd and boosters ❑ with projectiles every it <br /> ❑ Other 13without projectile <br /> - :�, . <br /> Seann9 Material ,,eaL.,,,.. '94/b bag/5-6 gal water) XSand Cement ) sack-,,x7 gai water Bentonite Pellets <br /> Bentonite(20%solids) Manufacturer Spec%solids_% Name <br /> �- <br /> Placement Method 4-Pumped Free Fall Other Specs on File Specs Submitted <br /> � <br /> Seal Completion Complete with Mushroom Capft bgs Complete to Existing Surface Pad <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN ! <br /> JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE,,-;IS„ <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ENI <br /> WORKERS COMPENSATION S. <br /> 1 M U. 'O UR ADVANCE NOTICE REQUIRED FOR INSFE TIO�JS <br /> -CEIVE® <br /> CONTRACTORS SIGNATURE TITLE Llk.)4 Z 16 DATE "ER <br /> 12 <br /> 2020 <br /> SAN JC'�QUIN <br /> EAT ONM N�q�TY <br /> DEPARTMENT <br /> 7 � H <br /> ..._._L__..._..._! .1 ._y-_.. ..._.j. ... <br /> i y.._.. <br /> I <br /> _ ..._..y.-... i 1 <br /> ® fi a <br /> 1 <br /> �:.... f <br /> ,....... <br /> r r.... �.... . 1 <br /> ;...r........~ 1 ....r 1 <br /> I _ !.... d... ,........ <br /> ... <br /> Ti <br /> �� 2 wC3o <br /> DEP-ARTMENT USE ONLY <br /> Application Accepted By Date Area <br /> Destruction Inspection By --_ -_71 2 ZO ZO <br /> DateEmployee ID# <br /> COMM NTS / O^ , <br /> PE SC Received Check#/ Amount Permit/ <br /> Codes Info B Cash Remitted Date Service est# Invoice# Well ID# <br /> Z)tai <br /> :1 1 )ZI <br /> EHD 43-08 V V <br />