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WELL DESTRUCTION PERMIT PUBLIC WATER SYSTEM ❑Yes ❑No SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 East Hazelton Avenue-STOCKTON CA 95205-(209)468-3420 NON-REFUNDABLE PERMIT f {{CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS L2 2- 6s'e � 1 K• CITY21P a Yl '7`(-cA CROSS STREET. I AP IN alb d "O PARCEL SIZP'nAND USE JAPPLICATION# �`n) OWNER #:e �Q y'6 PHONE�� q_32-2- OWNER ADDRESS (+� [ �4 ' I r� CITY/STATE/Z P ryi,,77 ,P¢7_`� , C-1 CONTRACTOR�� GSC. 1I5 Dr I ih 7 ��C` PHONE r �- A .L.CI -CQNTRACTOR ADDRESS I �'' ,)P,1 / CITY/STATE/ZIP MT:'d f S ^'% y `C��-7 C(5 C-57 WELL DRILLING LICENSE NUMBER (11��G^_+�� EXPIRATION DATE PERFORATION CONTRACTOR PHONE PERFORATION CONTRACTOR ADDRESS CITY/STATE/ZIP ❑ 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 Cl California Occupational Safety He Ith-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 Open Bottom ❑ Gravel Pack ❑ Uncased ❑ Other Well Log copy attached ❑ Yes XNNo Grout Seal ❑ No ❑ Yes it below ground surface(bgs) Hole Diameter inches Well Conductor Casing❑ Yes"*No Depth of Conductor Casing-ftbgsDiameter of Conductor Casing Inches Well Casing Diametdr !6 1 inches Total Depth M6- ft Depth to Water ft Depth of Casing ft bgs DESTRUCTION SPECIFICATION Sealing Material from Q ft bgs to _ft bgs Filler Material from It bgs to ft bgs Well casing to be perforated by one of the following methods; from ft bgs to ft bgs ❑ Mills Knife Number of cuts every ft and/or ❑ Explosives❑ Detonating cord ❑ with projectiles every It ❑ without projectile ❑ Detonating cord and boosters ❑ with projectiles every ft ❑ without projectile ❑ Other Sealing Material ❑ Neat Cement(94 lb bag/5-6 gal water)❑ Sand Cement sack mix/7 gal water ❑ Bentonite Pellets XI Bentonite(20%solids) ❑ Manufacturer Spec%solids_% Name ❑ Specs on File ❑ Specs Submitted Placement Method ❑ Pumped ❑ Free FaIL� ❑ Other Seal Completion 4] Complete with Mushroom Cap „5 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 COMPENSATION LAWS. MINIMUM HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS CONTRACTORS SIGNATURE �:�._-'".A*'�'"� TITLE `� DATE /7- z V N N I - I 1 EPARTMENT USE ONLY Application Accepted By %' � Date -- �' � Area Destruction Inspection By Date Employee ID# COMMENTS PE SC Received CF1eck# Amount Date Permit/ Invoice# Well ID# Codes Ifo j3y s Flemitted Service Request# )o EHD 43-08 - WELL DESTRUCTION PERMIT