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0 WELL DESTRUCTION PERMIT <br /> Pub-WATER SYSTEM ❑Yes ❑No <br /> SAN JOADUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 E MAIN STREET-STOCKTON CA 95202 -(209)468-3420 <br /> EXPIRES 1 YEAR FROM DATE ISSUED <br /> NON-REFUNDABLE PERMIT n <br /> //�� ,�{{ / L{ Aea CITyalp <br /> JOB ADDRESS '"1•'4� 1y L-`�'I♦t ✓�����n -=e y <br /> ' PARCEL SIZE_LAND USE APPLICATION# <br /> CROSS STR�EE/T� 1'TGa y APN �p ^ _1 <br /> OWNER INA Ctir s �'�P l` !� I�Q.+•a+t LL 1 - j1pC HONE 1 �"Y�.PA' '.(' N <br /> CITYISTATEIZIP e- A`O <br /> OWNER ADDRESS � ` �J �7 <br /> CONTRACTOR L.A-LA, S�pL f� J PHONE ,J0 `-7�— <br /> 3 � Z b✓1 L J r+ CITYISTATEIZIP �� C 3 f <br /> CONTRACTOR ADDRESS <br /> EXPIRATION DATE <br /> C-57 WELL DRILLING LICENSE NUMBER <br /> C� � <br /> PERFORATION CONTRACTOR / PHONE <br /> PERFORATION CONTRACTOR ADDRESS CITYISTATE21P <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 <br /> San Joaquin County Sheriff-Coroner Explosives Application and Permit License Number Expiration Date <br /> California Occupational Safety Health-Blaster License Number Expiration Dale <br /> REASON FOR DESTRUCTION ❑ Dry ❑ Replacement Well ❑ Caved In ❑ Pit Well Inactive ❑ Test Hole <br /> Detected I Suspected Well Water Contaminant(s) <br /> Adjacent property with contamination(Address) <br /> Known Soil I Water contaminants at adjacent property <br /> EXISTING WELL CONSTRUCTION DETAILS ❑ Open Bottom 0 Gravel Pack ❑ Uncased ❑ Other <br /> Well Log copy attached ❑ Yes ❑ No Grout Seal ❑ No '0 Yes It below ground surface(bgs) Hole Diameter _inches <br /> Well Conductor Casing❑ Yes X No Depth of Conductor Casing ft bgs Diameter of Conductor Casing inches <br /> Well Casing Diameter L inches Total Depth _ft Depth to Water_1 J ft Depth of Casing It bgs <br /> DESTRUCTION SPECIFICATION /� a <br /> Sealing Material from �_ft bgs to�ft bgs Filler Material N p,4 r►+—from ft bgs to_ +_it 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 It and I or <br /> ❑ Explosives❑ Detonating cord ❑ with projectiles every ft ❑ without projectile <br /> ❑ Detonatin�cordand oosters projectiles every ft ❑ withoutprojectile <br /> Other O t r� 6 -_ /0 PSJ- <br /> Sealing Material eat Cemag/5-6 ga�S.,ds <br /> Sand Cement sack mix 17 gal water Bentonite Pellets <br /> Bentonite(20%solids) pec _% Name Specs on File Specs Submitted <br /> Placement Method Pumped Free Fall Other <br /> Seal Completion Complete wit us, <br /> Cap ft bgs Complete to Existing Surface Pad <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> TITLE ,p .4- DATE <br /> CONTRACTORS SIGNATURE / �' / <br /> W45 <br /> 5 <br /> q-3,Z cn ijI","f,(yrs-( Glc l CAA, 4ter 3 V--C ce,-- t5 <br /> � � U � Z 6-a5 <br /> DEPARTMENT USE ONLY <br /> Application Accepted By Date Z Z Area <br /> Date Employee ID# <br /> Destruction Inspection By U( <br /> COMMENTS 1 91 <br /> COMMENTS <br /> n <br /> Eod <br /> SC Received Check#/ Amount Date PermiU Invoice# Well ID# <br /> Info B Cash Remitted Service Re uest# <br /> Zs 3 <br /> WELL DESTRUC71ON PERMIT <br /> EHD 43-OB <br /> 10&07 <br />