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ra WELL DESTRUCTION PERMIT PUBLIC WATER SYSTEM ❑Yes ®No SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPT 1868 East Hazelton Avenue-STOCKTON CA 95205-6232-(2`09)468-3420 NON-REFUNDABLE PERMIT C CALL 209 953-7697 OR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS E C],, CrrY21PQ 0►Y�AaA(,f 9 5:5 t/p, CROSS STREET L�7 �.ln f- 0APNZ,Z,g-121ni,-Z!5 PARCEL SIIZZE/%_nAND USEAPPLICATION# O OWNER a PHONE�.J LO �/�5C)LI -C1, 10 OWNER ADDRESS_^ 11� G (� ^^ /� ��((""''''^^ CITYISTATEfZJP C-as�]rQ[�Vw ley. C A CONTRACTORInnir (AJ1 1�T-�. Qr.l�\S AQ CD, rE#)C.PHONE J4/�,�/y� �- )1195 'q4 5u CON 7`RR TOR ADDRESS 1-1 ` -Q/� CITY/STATE/ZIP f/j 6d CS�O I C"A 96 3 5� IK C-57 WELL DRILLING LICENSE NUMBER 2— `LJ e 1 3 EXPIRATION DATE 5— PERFORATION CONTRACTOR PHONE PERFORATION CONTRACTOR ADDRESS CrTYISTATE/ZIP C-57 Well Drilling License Number 2-01018) 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 California Occupational Safety Health-Blaster License Number Expiration Date REASON FOR DESTRUCTION ❑ Dry Replacement Well ❑ Caved In ❑ Pit Well ❑ Inactive ❑ Test Hole Detected/Suspected Well Water Contami ants) Adjacent property with contamination(Address) Known Soil/Water contaminants at adjacent property-- EXISTING WELL CONSTRUCTION DETAILS CO3Open Bottom ❑ Gravel Pack E3Uncased ❑ Other Well Log copy attached ❑ Yes No Grout Seal ❑ No ❑ Yes___ It below ground surface(bgs) Hole Diameter inches Well Conductor Casing❑ es No Depth of Conductor Casing It bgs Diameter of Conductor Casing Inches Well Casing Diameter inches Total Depth [S6 Depth to Water ft Depth of Casing _ ft bgs DESTRUCTION SPECIFICATION LS - Sealing Material from it bgs to 150 ft bgs Filler Material_ from __ ft bgs to _ ft bgs Well casing to be perforated by one of the following methods: from It bgs to ft bgs ❑ Mills Knife ber of cuts every ft andelr ❑ Explosives❑ D ng cord ❑ with ctiles every ft ❑ without projectile etonating cord and boosters ❑ projectiles every ft ❑ Without projectile ❑ Other SeSment 9 Material Neat Cement(941b bag/5-6 gal water) Sand Cement sack mix/7 gal water Bentonite Pellets Bentonite(20%soli)s) Manufacturer Spec%solids % Name Specs on File Specs Submitted PMethod IS. Pumped Free Fall Other Seal Completion 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 24 HOUR�A�D/VANCE NOTIC R�//CYQUIRE {/J� CONTRACTORS SIGNATURE l • T� ��r DATE 1 —i yF ti�Ro V ?�?� _CTti°p F M 0Nrr I FHT .-1-; - - --- - - - - -1 F.T7 I DEPARTMENT USE ONLY �] Application Accepted By�s/�/L Data S ,; zo� Area q q C/ DestructionlnspectionBy Date EmployeeID# Sly COMMENTS y1 f/10r C 1 lbe I I 11 ohjch ,r►I�Jtt Infe►4efe h,.j r+h pall rve KC1;6kV4 O��d✓leS '1t PE SC Received Cheddl Amount Permit/ # Well ID# Codes Into B ash Remitted Date Service Re st# 43(�F o ro ,>ka i t' EHD 43-08 WELL DESTRUCTION PERMIT 10/5/07