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WELL DESTRUCTION PERMIT PUBLIC WATER SYSTEM ❑Yes ANo SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 East Hazelton Avenue-STOCKTON CA 95205 - (209)468-3420 NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS /3'61 L WLI 7— ic f c CITvrzIP /Oc -W—,1d 1� m CROSS STREET / Ih/��''��T/�41//Z� AP"N -Z 1L 7 PARCEL SIZE I0•6 LAND USE APPLICATION# OWNER////CSL Iale,' 6117-9 ( 7C It 1, 1 Y !R/iYf�ILi 7.s s� PHONE -2,/ 7 �/ 7 OWNER ADDRESS /-14/1 Zs A 2:1-)ter%' ��/�` �'�� CITY/STATE/ZIP ZU!// C'/1 ��S V 7 CONTRACTOR) 5/,7-1 �!i l�/r1'i /�C PHONE_?L��% 7 2 Z Z-7'5 "7 � CONTRACTOR ADDRESS 40 i X CITYISTATE21P g C-57 WELL DRILLING LICENSE NUMBER AZY76>11J EXPIRATION DATE CCAS �/ — Ali 2a PERFORATION CONTRACTOR :Pe, a C-4 L / PHONE �/11&' PERFORATION CONTRACTOR ADDRESS 64,V//' Cf.a k C,/,F j 7 J/ll% CITY/STATE/ZIP C-57 Well Drilling T License Number K Expiration Date Bureau of Alcohol,Tobacco and Firearms-Users of High Explosives License Number ��A-G�i7r '-T raTo--nnF'04-aV '111h) CHP Hazardous Material Transportation for Explosives License Number Expiration Date 30 San Joaquin County Sheriff-Coroner Explosives Application and Permit License Number --U Expiration Date California Occupational Safety Health-Blaster License Number Expiration Date / Z REASON FOR DESTRUCTION ❑ Dry ❑ Replpc5ment Well . ❑ Caved In ❑ Pit Well '5t Inactive ❑ Test Hole Detected/Suspected Well Water Contaminant(s) DA-e r1: c 4, 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 I$( No Grout Seal ❑ No ❑ Yes It below ground surface(bgs) Hole Diameter_ inches Well Conductor Casing ❑ Yes �i No Depth of Conductor Casing __ _ It bgs Diameter of Conductor Casing inches Well Casing Diameter_r_�__/inches Total Depth 1211 it Depth to Water--/2 y ft Depth of Casing VIA_it bgs DESTRUCTION SPECIFICATION �' Sealing Material from _�It bgs to /2 L It bgs Filler Material /�� u,4 from ig ft bgs to 1,7V 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 It and/or Explosives ❑ Detonating cord ❑ with projectiles every It ❑ without projectile fd Detonating cord and boosters ❑ with projectiles every it ❑ without projectile ❑ Other Sealing Material Neat Cement(94 lb bag/5-6 gal water) Sand Cement /(2• j sack mix'7 gal water Bentonite Pellets Bentonite(20%solids) Manufacturer Spec%solids` % Name Specs on File Specs Submitted Placement Method Pumped Free Fall Other Seal Completion j( Complete with Mushroom Cap _ it bgs x 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. c MINI HOUR AD ANCE TICE REQUIRED FOR INSPECTIONS t -7 CONTRACTORS SIGNATURE TITLE f J-e-,'G i%/J DATE J J �f/� �G t✓ I i PA Pec ��ED MAY e� SAN Joq 06 HEALTH 0 Pq RN q L 7y TMENT 1, / DEPARTMENT USE ON Y L' Application Accepted By L Date s S-/70 Z 0 Area _7/ /1 Destruction Inspection By Date 2 A :rte Employee ee ID# COMMENTS the of the 66?S+'l4 -,A01 LivSf be c ec,,ed t-,p P hvn1>1e 4e ZIPlY obs 1ru6}IahS W n ch h4 itih f ,r)ty r Cr vl >`6 e [Frc}Iv e hns r i :Jure e i Vla co 2 X/ i/1 I~✓ PE SC Received Check#/ Amount Date Permit/ Invoice# Well ID# Codes Info B Cash Remitted Service Request# L4 3,71-1 16� 3as 5 20 p00 EHD 43.08J x I-7 Z�� WELL DESTRUCTION PERMIT 4/30/12 4/30/12 ` -2 /