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WELL DESTRUCTION PERMIT PUBLIC WATER SYSTEM ❑Yes ❑No SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPT 1868 East Hazelton Avenue-STOCKTON CA 95205.6232 -(209)468-3420 NON-REFUNDABLE PERMIT CAL' (20091 983-769.'=GR i.1'S?= EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS < N CITY/7JP �K D '•I df CROSS STREET APN /� o .001 DQZ PARCEL SIZZI"LAND USE APPLICATION# O OWNER vrs t7 o PHONE M OWNER ADDRESS /CC CITY/STATE/ZIP Q i CONTRACTORr it .1 _PHONE_2_Q - 7 5 L/2 6, CONTRACTOR ADDRESS ° CITY/STATE/ZIP Nr_ b,[' r� 9 3 'J pB �v C-57 WELL DRILLING LICENSE NUMBER �-��L� —EXPIRATION DATE Jr / 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 California Occupational Safety Health-Blaster License Number Expiration Date REASON FOR DESTRUCTION ❑ Dry ❑ Replacement Well ❑ Caved In ❑ Pit Well g-hmVive ❑ Test Hole Detected/Suspected Well Water Contaminant(s) Adjacent property with contamination(Address) -- Known Scil/Water contaminants at adjacent property EXISTING WELL CONSTRUCTION DETAILS ❑ Open Bottom SK Gravel Pack ❑ Uncased ❑ Other Well Log copy attached ❑ Yes [!r-No Grout Seal ❑ No ❑ Yes ft below ground surface(bgs) Hole Diameter inches Well Conductor Casing❑ Yes W No Depth of Conductor Casing ft bgs Diameter of Conductor Casing inches Well Casing Diameter�M inches Total Depth ��• ft Depth to Water it Depth of Casing V6 ft bgs � g DESTRUCTION SPECIFTCATIO\ Sealing Material from it bgs to—` ft bgs Filler Material A°T from kg it bgs to r:;, it 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 ft ❑ without projectile j ❑ Other ro eve ❑ Detonating cord and boosters ❑ with projectiles P ❑ without projectile 1 every ft Seal-in�Material Neat Cement(94/b bag/5-6 gal water) Sand Cement sack mix/7 gal water Bentonite Pellets vBentonite(20%solids) Manufacturer Spec%solids_% Name L✓ Specs on File Specs Submitted j Placement Method humped Free Fall Ot er Seal Completion Complete with Mushroom Cap Yr 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 I 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 WS. iNIM 4 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTI NS CONTRACTORS SIGNATURE TITLE�'�Ata y�,-� DATE _.,... _.......I...-_.i_�.I..„._.�.._... �..�...... 4 I 4..._. t ,....., , t.. Q .._. �._.. . . , E.. all,..� .... __..........__..111...__ �.. j._... A _.......... Nit ...._....�............. fid 1 I , ..4.... _v..... . ......... q k-: i -...p........I.._........ J _ ...I Ilio 2®� _... . 10 R M E N T U S E Q LY HE9�V/ -/IV CQU/y Application AcceptedBy - Date Area Destruction Inspection By ~ r• Date 7��kill Employee ID# M�NT COMMENTS o V - �,Vi- 7_0 O-7 o vLS PE SC Received Amount Pemlit/ Codes In B Cash emitted Pate Service Re uest# Invoice# Well ID# MI 11A)DAI WOL401 S EHD 43-08