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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)468-342( NON-REFUNDABLE PERMIT CALL 299 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED // D o 1 JOB ADDRESS {(N h.Af\e Rek CITY/ZIP � G� d�� .1 Im CROSS STREET �fiJTn /Jlr F 4:rneR APN 2S 3^Q/Q—Of0—000 PARCEL SIZE USE APPLICATION# �D+`'P OWNER PHONE 60;.-322-25-05 I�TrN� ��eehG OWNER ADDRESS eo Al"Cl! �5 , �'{d /03v CITYISTATE/ZIP Om4c, , NL:- 6_82 7 CONTRACTOR 0.S LL, P �• ' PHONE `/10-923- CONTRACTOR /10-923•- �/ r CONTRACTOR ADDRESS -7 7.3 0 SPI 4^r e CITY/STATE/ZIP�(�0/'p•�� , /'' 7� eS3`J C-57 WELL DRILLING LICENSE NUMBER, l6 5$3 3 6 EXPIRATION DATE �J/ a0�12. 1 PERFORATION CONTRACTOR G �C^� ��II / PHONE V90- b Z3- iy3-7 PERFORATION CONTRACTOR ADDRESS 7273!3 0 / �a�lP CITY/STATE/ZIP �� 4 Z Kc3el-5 ,a C-57 Well Drilling License Number 105'5(.3 Expiration Date �T Z Bureau of Alcohol,Tobacco and Firearms-Users of High Explosives License Number gp -CA-v2 -s?$w Expiration Date CHP Hazardous Material Transportation for Explosives License Number Expiration Date San Joaquin County Sheriff-Coroner Explosives Application and Permit License Number 430—O) Expiration Date California Occupational Safety Health-Blaster License Number 17,701 Expiration Date REASON FOR DESTRUCTION ❑ Dry ❑ Replacement Well ❑ Caved In ❑ Pit Well Inactive ❑ Test Hole Detected/Suspected Well Water Contaminant(s) /t/0��Q Adjacent property with contamination(Address) Known Soil/Water contaminants at adjacent property EXISTING WELL CONSTRUCTION DETAILS ❑ Open Bottom ❑ Gravel Pack ❑ Uncased X Other 44-5 to -Agd- +v1 Well Log copy attached ❑ Yes >L No Grout Seal ❑ No ❑ Yes ft below ground surface(bgs) Hole Diameter inches Well Conductor Casing ❑ Yes ❑ No Depth of Conductor Casing ft bgs Diameter of Conductor Casing inches Well Casing Diameter.inches Total Depth I J;5 ft Depth to Water 86 ft Depth of Casing /Ss ft bgs DF.STRnCIJON SPECIFICATION Sealing Material from 0 ft bgs to /,CS_ ft bgs Filler "Material � from ft bgs to ft bgs Well casing to be perforated by one of the following methods: /,N((5 ga4d ifrom O ft bgs to /S S ft bgs W Mills Knife -Z Number of cuts every 4' ft and/or �I Explosives A Detonating cord ❑ with projectiles every 10 ft ❑ without projectile ❑ Detonating cord and boosters ❑ with projectiles every ft ❑ without projectile ❑ Other Sealing Material X Neat Cement(94 lb bag/5-6 gal water) Sand Cement sack mix/7 gal water Bentonite Pellets Bentonite(20%solids) Manufacturer Spec%solids % Name_ Specs on File Specs Submitted Placement Method x 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 48 OUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS CONTRACTORS SIGNATURE ( TITLE /DVjgtL A%it!ffe,�— DATE 1`�/) 'ris 1 _ . _ ......_.. _. . _. j_ ..... PA AJ6A G/ r l -'` _.......!. ............ 1....................s....- ......_p...._ ._ . __.. _ _...... _i. I j 1 _'.... VE I I ; i T d...........:....... ......... .. ! ... ............ .........._i............}.........h..... f.. i / ... ..;. ..:.__. ; . ....... a...... 14 i I I i ............... # FF ...q........�.........t._... ...._...._.-......_........._..............Z... ..S. }..... .. ...I __ l. _T.___--1 .__-L_-...I_...,,..{ �4 I I _........_ ._...... p l._ _ a SAA J 10 i N ... qTERNCO 0 A/TH1 .... ...._......t... ........i..........t....... rM ..... ...... i .. ... . .t . . .. ..y }.. ....I_ 1._ I �... .L. .... 1 - 1I r DEPARTMENT USE O2/-?Y Application Accepted By �` Date /a D�oO Area Destruction Inspection By L Date �� SSI !)�+[X� Employee ID# DA COMMENTS P407 �T lbS/Y PE SC Received Check#/ Amount Permit/ Codes Info B Cash Remitted Date Service Request# Invoice# Well ID# g37y 16S133a- EHD 43-08 //��13 WELL DESTRUCTION PERMIT