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WELL DESTRUCTION PERMIT <br /> e T 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 CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> am/}Aa ^ rn <br /> JOB ADDRESS �d O 2 tt CITY2y <br /> 1P //C, C V CA <br /> +~i <br /> CROSS ST EE.T I'r r C APN / PARCEL SIZEY—AAN�DUSE APPLICATION# <br /> OWNER I G PHONE - c/a&O / YR <br /> OWNER ADDRESS —CITY/STATE/ZIP 2,e*12 la C.44. <br /> CONTRACTOR W •� PHONE O 6 - L�2 6 <br /> CONTRACTOR ADDRESS /� a CITY/STATE2IP C�it <br /> Ar., <br /> C-57 WELL DRILLING LICENSE NUMBER ! y d EXPIRATION DATE 7�A -/7 <br /> PERFORATION CONTRACTOR PHONE <br /> PERFORATION CONTRACTOR ADDRESS CITY/STATE/ZIP <br /> ❑ C-57 Well Drilling License Number Expiration Date <br /> Bureau of Alcohol,Tobacco and Firearms-Users of High Explosives License Number Expiration Dale <br /> CHP Hazardous Material Transportation for Explosives License Number Expiration Date W <br /> San Joaquin County Sheriff-Coroner Explosives Application and Permit License Number Expiration Dale <br /> California Occupational Safety Health-Blaster License Number Expiration Date <br /> tp <br /> REASON FOR DESTRUCTION ❑ Dry ❑ Replacement Well ❑ Caved In ❑ Pit Well GYTnactive ❑ Test Ole <br /> Detected/Suspected Well Water Contaminant(s) <br /> Adjacent property with contamination(Address) <br /> Known Soil/Water contaminants at adjacent property <br /> EXISTING WELL CONSTRUCTION DETAILS ❑ Open Bottom ❑ Gravel Pack ❑ Sed ❑ Other <br /> Well Log copy attached ❑ Yes ❑ No Grout Seal ❑ No ❑ Yes ft below ground ce(bgs) Hole D' ter inches <br /> Well Conductor Casing Yes ❑ No Depth of Conductor Casing ft bgs Diameter of Cond Casing inches <br /> Well Casing Diameter inches Total Depth ft Depth to Water (2 ft De of Casing ft bgs <br /> DESTRUCTION SPECIFICATION' <br /> 1 1 !• <br /> Sealing Material from 0 ft bgs to qy.�� ft bgs Filler Material T J it i roO ft bgs to ft bgs <br /> Well casing to be Perforated by one of the following methods: from ft bgs to ft bgs <br /> ❑ Mills Knife Number of cuts every ft and/or <br /> ❑ Explosives❑ Detonating cord ❑ with projectiles everyft ❑ without projectile <br /> ❑ Detonating cord and boosters ❑ with projectiles every ft�(n ❑ without projectile <br /> ❑ Other V <br /> Sealing Material Neat Cement(94 Ib bag/5-6 gal water) d Cement sack mix/7 gal water Bentonite Pellets <br /> �ntonite(20%solids) ufacturer Spec%solids Name Specs on File Specs Submitted <br /> Placement Method umped Free Fall that <br /> Seal Completion Complete Ith Mushroom Cap bgs Complete to Existing Surface Pad <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THI AF`4 CATION ANqeTHAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> JOAOUIN COUNTY ORDINANCES, STATE LAW RULE$ AND REG TIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT AND ACTIVE WITH T CALIFORN CON C76RS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LA —'lf <br /> MI MUM Uv NCE NOTICE REQUIRED <br /> /FOR <br /> �IN�SPECTI S4 <br /> CONTRACTORS SIGNATURE fff TITLE( /lC DATE <br /> V <br /> IK PAY1"e <br /> UG 13 2019 <br /> SAN AQu� <br /> V I � O �cri IRONME ME <br /> DEPART NT <br /> DEPARTMENT USE ON <br /> OApplication Accepted By Date Area �`�f <br /> Destruction Inspection By a Employee ID# 1 - <br /> COMMENTS -- <br /> 1 <br /> PE Sc Receivedhec Amount Date Permit] Invoice# Well ID# <br /> Codes Info B ash Remitted Service Re uest# <br /> 5 <br /> EHD 43-08 WELL DESTRUCTION PERMIT <br /> revised 4/14/18 <br />