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WELL DESTRUCTION PERMIT t PUBLIC WATER SYSTEM ❑Yes)(No SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPT 1868 East Hazelton Avenue-STOCKTON CA 95205-6232-(209)4683420 NON-REFUNDABLE PERMIT -L 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS '1 NJ e . I� CITY2IP O CROSS STREET W•+CG \��'��AP O7 ('3�O '1 ZPARCEL SIZE LAND USE/APPLICATION# OWNER pt Ir,,rms PHONE L-� — 41/01 - ober-'r /� i OWNER ADORES-y y91, t 1 {CQ 8'QW ��J C. CITY/STATE/LP rl fes. IZA 0 CONTRACTOR �j ' Q PHONE 4 CONTRACTOR ADDRESS, J 1�.� 1.1 CITY/STATE/LP LLLL -57 WELL DRILLING LICENSE NUMBER2g O8 4�,/ EXPIRATION DATE �J L PERFORATION CONTRACTOR PHONE PERFORATION CONTRALTOAAeVRTSS CFFYISTATE/ZIP C-57 Well Drilling License Number _ Expiration Date N !- 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 Contaminant(s) 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 No Grout Seal ❑ No ❑ Yes ft below ground surface(bgs) Hole Diameter_ inches Well Conductor Casing❑ Yes No Depth of Condu yfor Casing ft bgs Diameter of Conductor Casing inches w160 Well Casing Diameter__, inches Total Depth+31. ft Depth to Water _-_ft Depth of Casing ft bgs DES]R11 TION SPE('IFR ATION Sealing Material from _JL.)__ft bgs to %per__ �ft bgs Filler Material_ _ from_ __ ft bgs to 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 ft and/or .- ❑ Explosives❑ Detonating cord ❑ with projectiles every _ft ❑ without projectile ❑ Detonating Cord and boosters ❑ with projectiles every _-, ft ❑ without projectile ❑ Omer.- - -- Sealing Material Neat Cement(94 lb bag/5-6 gal wafer) Sand Cement sack mix/7 gal water Bentonite Pellets xBentonite(20%solidManufacturer Spec%solids % Name Specs on File Specs Submitted Placement Method Pumped Free Fall Other Seal Completion Complete with Mushroom Cap 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 74 IiOUR ADVANCE NOTIrE REn!J.RFD FOR NFPrCTJnN CONTRACTORS SIGNATURE V1A "T101 TITLE ♦ DATE`7 L'7 - - -- - - RgyME e s AI q1 ? O ?0? 0 tiFqNv��- 0, Coo y L.. DEPARTMENT USE ONLY. Application Accepted By-9-- L�- Data // 1?0 Area o? �L Destruction Inspection By t Date 1010 Employee ID# rA COMMENTS -r"-I.( a16 �S PE SC Receiveo he Amount Date PertniU Invo �JlY Well ID# Codes Info as Remitted Service Request# •3i3 �;1 ,�d�is 00�l11� 7 EHD 43-08 WELL DESTRUCTION PERMIT 10/5/07