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WELL DESTRUCTION PERMIT <br /> PUBLIC WATER SYSTEM❑Yes ❑No <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE 3"°FL-STOCKTON CA 95202 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL(209)953-7697 FOR INSPECTIONS EXPIRES I YEAR FROM DATE ISSUED <br /> JOB ADDRESS �'• uJ I CITY/ZIP <br /> 0 D <br /> CROSS STREET S -a - APN� yam/ 7 PARCEL SIZE LAND USE APPLICATION# <br /> O <br /> " 38' <br /> I Q r Pxorve <br /> OWNER � <br /> OWNER ADDRESS Z J CITY/STATV1ZIP <br /> CONTRACTOR -/l.f � PHONE <br /> CONTTRRACTOR ADDRESS 1 I •P✓` p/ CITY/STATE/ZIP <br /> M C-57 WELL DRILLING LICENSE NUMBER� e.G EXPIRATION DATE <br /> PER✓✓✓FOORATION 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 Conlaminant(s) <br /> Adjacent property with contamination(Address) <br /> Known Soil/Water contaminants at adjacent property <br /> EXISTING WELL CONSTRUCTION DETAILS ❑ Open Bottom Al�Gravel Pack ❑ Uncased ❑ Other <br /> Well Log copy attached ❑ Yes ;2)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_ �inches Total Depth�ff��' R Depth to Water_fl Depth of Casing R bgs <br /> DESTRUCTION SPECIFICATION <br /> Sealing Material from ft bgs to ft bgs Filler Material from 14r!Q ft bgs to It bgs <br /> Well casing to be perforated by one of the following methods: from te ft bgs to ft bgs <br /> ❑ Mills Knife Number of cuts every ft and/or <br /> ❑ Explosives ❑ Detonating cord ❑ with projectiles everyit ❑ without projectile <br /> ❑ Detonating cord and boosters ❑ with projectiles everyft ❑ without projectile <br /> ❑ Other ta�y/ <br /> Sealing Material [I Nest Cement(94 lb bag/S-6 gal water) ❑ Sand Cement sack mix/7 gal water vp Bentonite Pellets <br /> ❑ Bentonite(20%solids) ❑ Manufacturer Spec%solids % Name ❑ Specs on File Specs Submitted <br /> Placement Method-0 Pumped DRr Free Fall ❑ her <br /> Seal Completion 4�W.Complete with Mushroom Cap 1 ftbgs Complete to Existing Surface Pad <br /> 1 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. 1 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 /> MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS n <br /> CONTRACTORS SIGNATURE 4'I �- L-�L's+� TrrL 1'v DATE t <br /> AUG 3 0 Zoon <br /> SAN JOAQUIN COUNTY <br /> _ - ! ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> —�� <br /> —9 E A-R- --U S--E- O N L Y <br /> ue,��Application Accepted By Dau IRP6 Area �Q <br /> Destruction Inspection By 3i I t "�� - - Date �� ,;i; Employee ID (�# �� [J9 <br /> COMMENTS <br /> i <br /> PE SC Received Chec Amount <br /> DtPermit/ Invoice# Well ID# <br /> Date Codes Info B Cash Remitted Service Request# <br /> 41 <br /> W,11 D.1-1 a Permit <br /> EHD 43-02-00A <br /> IR7/2005 <br />