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WELL DESTRUCTION PERMIT <br /> PUBLIC WATER SYSTEM ❑Yes ❑No <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 600 E MAIN STREET-STOCKTON CA 95202-(209)468-3420 <br /> NON-REFUNDABLE PERMIT ` CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEfiRFROM DATE ISSUED <br /> JOB ADDRESS CITYIZIP <br /> (,n <br /> CROSS STREET APN PARCEL SIZ �7 LAND USE APPLICATION# c <br /> OWNER �1 L /PHONE 1 Z' Q v <br /> n <br /> OWNER ADDRESS CITY/STATE/ZIP <br /> � r <br /> CONTRACTOR_ '-x Ir' L�I{�. PHONE <br /> CONTRACTOR ADDRESS CITY/STATE/ZIP <br /> 7 / <br /> C-57 WELL DRILLING LICENSE NUMBER S 3 �- EXPIRATION DATE F+•�7— <br /> PERFORATION CONTRACTOR PHONE <br /> PERFORATION CONTRACTOR ADDRESS CITY/STATE/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 Sheriff-Coroner Explosives Application and Permit License Number Expiration Date <br /> ❑ California Occupational Safety Health-Blaster License Number Expiration Date <br /> REASON FOR DESTRUCTION ` Dry ❑ Replacement Well ❑ Caved In ❑ Pit Well ❑ Inactive ❑ Test Hole <br /> Detected/Suspected Well Water Contaminant(s) <br /> Adjacent property With contamination(Address) <br /> Known Soil/Water contaminants at adjacent property <br /> EXISTING WELL CONSTRUCTION DETAILS ❑ Open Bottom ❑ Gravel Pack ❑ Uncased ❑ Other <br /> Well Log copy attached ❑ Yes JCI.No Grout Seal ❑ No ❑ Yes ft below ground surface(bgs) Hole Diameter inches <br /> Well Conductor Casing❑ Yes t!r No Depth of Conductor Casing ft bgs Diameter of Conductor Casing inches <br /> Depth to Water <br /> Well Casing Diameter inches Total Depth ft ft Depth of Casing ft bgs <br /> DESTRUCTION SPECIFICATION C4-1 r <br /> Sealing Material from ).ft bgs to ftbgs Filler Material /�SN!�� ! from ft bgs to ft 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 ft and/or <br /> ❑ Explosives❑ Detonating cord ❑ With projectiles everyft ❑ without projectile <br /> ❑ Detonating cord and boosters ❑ With projectiles everyIt ❑ without projectile <br /> ❑ Other <br /> Sealing Material - Neat Cement(94 Ib bag75-6 gal wafer) . Sand Cement sack mix/7 gal water < Bentonite Pellets <br /> Bentonite(20%solids) Manufacturer Spec%solids_% Name Specs on File - Specs Submitted <br /> Placement Method Pumped ,e 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 /> MI IMUM' HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br /> CONTRACTORS SIGNATURE i _TITLE6(.,;iAA- DATE 7— Z <br /> �J r <br /> - } PAYMENT <br /> RECEIVED <br /> JUL 12 2019 <br /> .SAN JOAQUIN COUNTY <br /> \ _ J ENVIRONMENTAL <br /> _ _I HEALTH DEPARTMENT <br /> DEPARTMENT USE ONIL <br /> Application Accepted By Date n Area Y w� <br /> Destruction Inspection By Date � r Emplo�yeeyI _ n <br /> COMMENTS <br /> PE SC Received CheckW Amount Date Permit/ Invoice# Well ID# <br /> Codes Info Cash Remitted Service Request# <br /> IZ I r <br /> EHD 43-08 WELL DESTRUCTION PERMIT <br /> 10/5/07 <br />