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WELL DESTRUCTION PERMIT PUBLIC WATER SYSTEM ❑Yes ❑No SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPT 1868 East Hazelton Avenue-STOCKTON CA 95205.6232 -(209)d68-3420 NON-REFUNDABLE PERMIT CALL 209 853-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS Sa' E r CITY/LP aC d-3 y CROSS STREET APN p ty /7 y PARCEL SIZE�LgND USE APPLICATION#__�� Y OWNER!a C✓✓•'` I� . /I[ •� �j O PHONE_�O7 OWNER ADDRESS itt, <'r /ft�-� ACITY/STATE21P�TOCn/ /'1 Cj� 9 a /JCONTRACTOR CONTRACTOR ADDRESS J K . PHONE 0 - - W 2 L' CRY/STATE21P�LfR S C CP4 14"C-57 •57 WELL DRILLING LICENSE NUMBER_ 7 3� / EXPIRATION DATE_E-3/ m PERFORATION CONTRACTOR Q /j PHONE /' ,,&- /O� PERFORATION CONTRACTOR ADORE S CITY/STATE/ZIP O O J Cf 4' C-57 Wel!Drilling License Number Bureau of Alcohol,Tobacco and Firearms-Users of High Explosives plrat on Date---vi-2,25 S` 0 9 P License Number t*3 7_ g t_ 7 ,�n�Date/�•/•2 a CHP Hazardous Material Transportation for Explosives San Joaquin County Sheriff-Coroner Explosives A License Number( g 7 6__/7 Expiration Date P Application and Permit License Number 3�C/ California Occupational Safety Health-Blaster Expiration Date/�• "a License Number_/t�J y/6 Expiration Date 7- REASON FOR DESTRUCTION ❑ Dry ❑ Replacement Well ❑ Caved In Detected/Suspected WeII Water Contaminants) ❑ Pit Well nactive ❑ Test Hole Adjacent Property with Contamination(Address) Known Soil 1 Water contaminants at adjacent property 7Well G WELL CONSTRUCTION DETAILS ❑ Open Bottom Log copy attached ❑ Yes Gravel Pack ❑ Uncased ❑ Other �o Grout Seal ❑ No ❑ Yes ftbelow round surface Conductor Casing❑ Yes �o De g (bgs) HoleDiameterinches a pkh of Conductor Casing ft bgs Diameter of Conductor Casinginches asing Diameter / 2 • inches Total Depth Pt 1-ft Depth to Water_ft Depth of Casing ft bgs _DESTREMO'Y P FICATIO+� 9 Sealing Material from P.2ft bgs to / ft logs Filler Material / CO A C Rr fr from ��/ ft bgs to�ft bgs Well as to be perforated by one of the following methods ❑ Mills Knife ----- from It bgs to ft bgs Number Of Cuts every ft and/or Explosives-Detonating cord ❑ with projectiles every p ft 70S - / Detq�a�i g cgr�f and booste ❑ With Projectiles every�—ft ❑ without projectile Cd Other�rit '..;)n ,•L,d� / r ❑ wthoutprojectle Sealing Material Neat Cement(94 1ag/5-6 gal water) Sand Cements s /O• sack mix/7 gal water Bentonite Pellets Bentonite(20%solid Manufacturer Spec%solids % Name Placement Method <mpedSpecs on File Specs Submitted Seal Completion Complete w Mushroom Cap Free Fall I w bgs Other YMENT :. Complete to Existing Surface Pad I I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IACCORDCE WITH N ANCEiVE® JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSESAN IS CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD � � ��7� AND THAT I AM IN COMPLIANCE WITH A" 7! WORKERS COMPENSATI N LAWS, fJ MIN M U ADVANCE NOTICE REQUIRED FOR INSPEffrIONS SAN JItIAQUIN COUNTY CONTRACTORS SIGNATURE TITLE T DATE 2—7^:Z 41 ENVIRONMENTAL H DEPARTMENT iI- I- I I - * t a 1 j T- •r___•r_�J.....__i ..L-... v—_ .... _.._,___ __..J , L t_ ir- Y-......f"""...a._... _....1... _... _.. f _..._ .._...._;.......1.._ i ._ h gEPARTMENT USE ONL Application Accepted By .� ' a Destruction Inspection By Date Area 2� 2 OMMENTS Date ZfiJ 1-J Employee ID# l�- e s1 ,0 ?�u PE SC Received Check*! Amount Codes Info Date DPermit/ Cash Remitted Service R uest Well ID# EHD 43-08