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WELL DESTRUCTION PERMIT <br /> P /1 PUBLIC WATER SYSTEM 0 Yes ❑No <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT ,,/ 600 E MAIN STREET-STOCKTON CA 95202-(209)4683420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> Joe ADDRESS CmRIP__R1T-Gt1 ��aj�j(Q M <br /> CROSS STREET / APN�'CJ'111/ PARCEL SIZE LV�j_LANDD USE APPPUCATION# p <br /> OWNER +� C y RI PHONE 1 991. E 02J A' f <br /> OWNERADDRESS_..._i J� U� S�• CITYISTATE21P i n CA 611g,3w _ <br /> CONTRACTOR 1 1 r PHONE 2 0 1- 22 • 1 4 -0 xr <br /> CONTRACTOR ADDRESSul pk _ CITY/STATEIZIP �L�Pft.�GA 9 J�J <br /> 0/C-57 WELL DRILLING LICENSE NUMBER \ t 012, _ EXPIRATION DATE_M <br /> PERFORATION CONTRACTOR PHONE <br /> PERFORATION CONTRACTOR ADDRESS CITYISTATE/ZIP <br /> ❑ C-57 Well Drilling License Number Expiration Date <br /> ❑ Bureau of Alcohol,Tobacco and Firearms-Users of High Explosives License Number Expiration Date <br /> ❑ CHP Hazardous Material Transportation for Explosives License Number Expiration Date <br /> ❑ San Joaquin County Shariff-Coroner Explosives Application and Permit License Number Expiration Date <br /> ❑ Califomia Occupational Safety Health-Blaster License Number Expiration Date <br /> REASON FOR DESTRUCTION YDry ❑ Replacement Well NF Caved In ❑ Pit Well ❑ Inactive ❑ Test Hole <br /> Detected/Suspected Well Water Contaminant(s) <br /> Adjacent property with contamination(Address) <br /> Known SaUWater contaminants at adjacent property <br /> EXISTING WELL CONSTRUCTION DETAILS ❑ Open Bottom ❑ Gravel Pack ❑ Uncased ❑ Other <br /> Well Log copy attached ❑ Yes ❑ No Grout Seal ❑ No ❑ Yes ft below ground surface(bgs) Hole Diameter inches <br /> Well Conductor Casing❑ Yes ❑ No Depth of Conductor Casing ft bgs Diameter of Conductor Casing inches <br /> Well Casing Diameter_U--inches Total Depth _It Depth to Water ft Depth of Casing ft bgs <br /> DESTRUCTION SPECIFICATION <br /> Sealing Material from ft bgs to ft bgs Filler Material from it bgs to ft bgs <br /> Well casing to be perforated by one of the following methods: from It bgs to it bps <br /> ❑ Mills Knife Number of cuts every ft and/or <br /> ❑ Explosives❑ Detonating cord ❑ with projectiles everyft ❑ without projectile <br /> ❑ Detonating cord and boosters ❑ with projectiles everyft ❑ without projectile <br /> ❑ Other <br /> SealI Material .: Neat Cement(94 lb bag/5-6 gal water)L. Sand Cement sack mix/7 gal water Bentonite Pellets <br /> Bentonite(20%sotjds) Manufacturer Spec%solids % Name Specs on File Specs Submitted <br /> Placement Method %/ Pumped Free Fall Other <br /> Seal Completion _: Complete with Mushroom 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 /> MJNO"M 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br /> CONTRACTORS SIGNATURE TITLE�ym& DATE <br /> i <br /> Ic4riVL� I i ._.. ...... <br /> w.. t a <br /> f >. i <br /> a + <br /> a p <br /> }...I.. y <br /> SANNvVIRONMENTALtt <br /> ... QUIN COUN <br /> ENT- — rJ <br /> 1..........,......;........;_,HEALTH <br /> DEPARTMENT- <br /> j <br /> y <br /> EP RTMENT USE O <br /> Application Accepted By Date <br /> Date Inspection By B Employee ID <br /> TS �U o 1 C #_ <br /> PE SC Received Check#1 Amount DaPermit/ Invoice# Well ID# <br /> Codes Info B Cash am• / te Service R uest# <br /> EHD 43-08 WELL DESTRUCTION PERMIT <br /> 10!5107 <br />