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WELL DESTRUCTION PERMIT - PUBLIC WATER SYSTEM �c ]No SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 600 E MAIN STREET-STOCKTON CA 95202-(209)469-3420 NON-REFUNDABLE PERMIT %J� CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRM '7 /r' J/ Ctiv/ZIP -1 CROSS STREET Lh. APN PARCEL SIZE_LAND USE APPLICATION# o Ah? v owNER_Ao//��! ?k )�r�. LL PHONE? G -�S OWNER ADDRESS J -zv/ Z / f CITY/STATE/ZIPC i /!fir /-4 CONTRACTOR I,L/,-x PHONE CONTRACTOR ADpRESS ;FG iGCldv✓ / CITY/STATE/ZIP JCr ,GST C-57 WELL DRILLING LICENSE NUMB/ER ExPIRATION DATE'111z01 I PERFORATION CONTRACTOR I'�F �'-r" t1/f�f /nr�/vr��dcrV PHONE %!7ry0 /1/ PERFO�ATgN CONTRACTOR ADDRESS �j}J CnY/STATE/ZIP Cl C-57 Well Drilling License Number L771 5 3 Expiration Date 1114O11 Bureau of Alcohol,Tobacco and Firearms-Users of High Explosives License NumberZ A; 'iKpkatlon Date L 1 CHP Hazardous Material Transportation for Explosives License Number 137 Z/7 Expiration Date 1Z a San Joaquin County Sheriff-Coroner Explosives Application and Peron License Number Expiration Date CaAfomia Occupational Safety Health-Blaster License Number Expiration Date REASON FOR DESTRUCTION ❑ Dry ❑ Replaceme9t WGN ❑ Caved In ❑ Pit Well ;,M.Inactive ❑ Test Hole It Detected/Suspected Well Water Contaminant(s) !i Adjacent property with contamination(Address) Known Soil/Water contaniklants at adjacent property Ex1STWG WELL CONSTRUCTIOII DETAILS Open Bottom O Gravel Pack ❑ Uncased ❑ Other Well Log copy attached ❑ Yes :V No Grout Seal ❑ No ❑ Yes __ Il below ground surface(bgs) Hole Diameter__ _ inches Well Conductor Casing❑ Yes ❑ No Depth of Conductor Casing _ft bgs Diameter of Conductor Casing _ inches WeN Casing Diameter---inches Total Dept11 - =-, R Depth to Water_ %Z_ft Depth of Casing_ _ it bgs DESTRUCTION SPECIFICATION _ Sealing b9 to Materiel from ft s Filter Material a r - r \ - ft — _..J from —S.%..._ft logs to_._ —ft logs Well casing to be)moo aid by om of the following methods: from C�) fl bgs tom_ft bgs ❑ )dims Knife _Number of cuts every ft and/or Explosives❑ Detonating cord r1 •with projectiles every It ❑ without projectile QrDetonabW cord and boosters with projectiles every_. O .ft 7111'without projectile ❑ OBIsr _ _ ._ Sealing Material k(94 lb bag/5-6 gal wafer) / Sand Ceme Ili,3 sack mux 17 gal water Bentonite Pellets Bentonite(20%soNds) - Manufacturer Spec%solids_% Name Specs on Fite Specs Submitted Placement Method Pumped) Free Fall Other Seat ComplatJon Complete with Mushroom Cap Z 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 1 AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION LAW INII 4 H ANCE 910E REQUIRED FOR INSPECTIONS y CQNTRACT0R3$IbrQ�uRe I \." DATE -� l 1. R 1I DEPARTNLENT USE ON Y Application y �Easd/L+ �� Date 1161 Area Destruction 1 By Date �G/g�0 Employee IDA y4t1Jr '�� CrOMMENTS 4. _ — y i�//i//�.� �� ✓07�irn . l�_J is//�.�ti 7�i�/'� i!-f��/i Gcwd T��,tf�Yl� PE SC Raaiwd Cho" Amount Date Permit/ A N Codes 61110 B Cash Remitted Service Request A -673 / -71 EHD 1308 yi��-d a UiG EI.L DESTRU Gi