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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)468-3420 NON-REFUNDABLE PERMIT CALL 209 953-7697 OR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS SO e . w arvmP �C 33 CROSS STREET �y • APN PARCEL SIZE �O {AND USE APPLICATION# p OWNER RO.�y• C nC C -3 meq- Q OWNER ADDRESS PHONE Q7 G f-r' � 2� �,y �f y J cfTY/STATE21P-xTOc/S a,1 CONTRACTOR a PHONE e. O •• - (�2 CONTRACTOR ADDRESS v a• q CITY/STATEIZIP_/ (tI� S C k CO 9"0/ 4'-C-S7 WELL DRILLING LICENSE NUMBER_ /j!p EXPIRATION DATE_ PERFORATION CONTRACTOR Q � /j PHONE /' ,*,I&- PERFORATION CONTRACTOR ADDRE S_ ©�( �3/� CtTI'/STATE2IP O OQ C� A C-57 Well Drilling Bureau of Alcohol,Tobacco and Firearms-Users of High Explosives License Number �7'3�/ / piration Date 9 P LicenseNumbei971?'J/J t�•e.+ 7 I CHP Hazardous Material Transportation for Explosivescense --- -�-- ton Date/ 2/•1 San Joaquin County Sheriff-Coroner Explosives Application and Permit License Number 31Number 7 01 Expiration Date g -q California Occupational Safety Health Blaster 3�� ExpiratonDate��• 8-ZQ License Number_/O`//6 Expiration Date �• •� E7K UCTION ❑ Dry ❑ Replacement Well ❑ Caved In cted Well Water Contaminant(s) Li Hit Well InactiveEEE❑ Test Hole rty with contamination(Address) EEEEter contaminants at adjacent property EXISTING WELL CONSTRUCTION DETAILC 11 Open Bottom Well Log copy attached ❑ Yes ❑ Gravel Pack ❑ Untried 11 Other ❑ No Grout Seal [DNo ❑ Yes ft below ground surface s Well Conductor Casing❑Z l ❑ No pe (bgs) Hole Diameter inches Depth of Con actor Casing ft bgs_ Diameter of Conductor Casing inches Well Casing Diameter inches Total Depth ft Depth to Water t,,� --t2_ft Depth of Casing ft bgs DESTRUCTION SP Fi ATION Sealing Material from /.,0 ft bgs to O ftbgs Filler Material G O/1 e R C{ Well casing to be perforated by one of the following methods: from _ftbgs to ft bgs v ❑ Mills Knife from ft bgs to ft bgs Number of cuts every ft and/or Explosives e-Detonating cord ❑ with projectiles every p ft 2706 j / n j� Detghetipg corll and booste ❑� with projectiles every�-ft ❑ without projectile 8/�4.V1 C-A� Cd Otherl-ritTC•t/17�d e�L.d� �s I��+�LJ GftAR4� QO A out projectile �/, 7 J' BT' Sealing Material Neat Cement(94/b ag/5-6 gal water) �,,/ Sand Cement ,! Bentonite(20%solids , /IL_sack mix/7 gal water Bentonite Pellets )/ManufadurerSpec/solids_% Name Placement Method Q Pumped Free Fall Specs on File Specs Submitted Seal Completion Complete wth Mushroom Cap S t Other ft bgs Complete to Existing Surface Pad 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 REQUIRED LICENSE IS CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL WORKERS COMPENSATI N LAWS, MIN M U ADVANCE NOTICE REQUIRED FOR INSPE IONS CONTRACTORS SIGNATURE TITLE ! DATE ' ......._F.._...p._ .t-.-._. 3 �. r.__.�,.._.�...__ . r , .. .. . ' }.._.. _ __ . . I if a I fl D E P A TM NT USE 0 N L ?� Application Accepted By Date �Q ZVArea � yRONy 'JN>?. Destruction Ins coon B Z Z COMMENTS Date Employee ID# r ENT A i c L-•9:-t K PE Sc eceived Chec Codes InfAmount o _ B Cash Remitted Date Servi eeR uest# Invoice# Well ID# EHD 43-08