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l ,l <br /> VVELL DESTRUCTION PERMIT <br /> PUBLIC WATER SYSTEM ❑Yee ❑No <br /> SAN JOAOUM COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 East Hazallon Avenue-STOCKTON CA 95205-(209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> y <br /> JOB ADDRESS yy� Cm/7rP <br /> CROSS ST ET 1 r 1 APN IDD—/t DGQ PARCEL�S�2/EW.L.AANNr;USE APPLICATION a <br /> OWNERrArAJ�U W PHONE�I/'� �'[T�`/]?W.(�00p?, , <br /> OWNER ADDRESS CIT1/STATE/ZJP TSCA ION.Ga q 631.0 <br /> CONTRACTOR PHONE <br /> CONTRACTOR ADDRESSJJ!J CRY/STATFIZIP <br /> la C-57 WELL DRILLING LICENSE NUMBER EXPIRATION DATE <br /> PERFORATION CONTRACTOR PHONE <br /> PERFORATION CONTRACTOR ADDRESS CrTY/STATFJZIP <br /> ❑ C-57 Wall Drilling LJcense Number Expiration Dale <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 Data <br /> ❑ San Joapuin County Sheriff-Coroner Explosives Application and Permit License Number Expiration Date A <br /> ❑ California Occupational Safety Health-Blaster License Number Expiration Date A Y <br /> REASON FOR DESTRUCTION Dry ❑ Replacement Well ❑ Caved In ❑ Pit Well ❑ Inactive ❑ Test Hole ��1."•/�A, <br /> Detected/Suspected W-11 Water Conta ninant(s) `c 7- <br /> Adjacent property with contamination(Address) O <br /> Known SdUWater contaminants at adjacent property <br /> ❑ Open Bottom yl Gravel Pack ❑ Uncased ❑ Other <br /> Well Log spy attached ❑ Yea No Grout Seal ❑ No ❑ Yes It below grand surface tbgs) Hole Diameter v�N <br /> Well Conductor Casing❑ Yes ❑ No Depth of Conductor Casing It bps Diameter of Conductor Casing _ in 0NMFCoON <br /> Well Gelnq Dlarnalsr o—IrICIIes Total Depth ADD—" Depth to Water K Depth of Caelnq Fp,4R ME�1/7' <br /> DESTRUCTION SPECIFICATION <br /> Sealing Material from it bgs to A-_R bgs Filler Material frau_ it bgs to it bgs <br /> Well using to be Perforated by one of the following methods: from R bgs to it bgs <br /> ❑ Mille Knife Number of cuts every h andror <br /> ❑ Explosives❑ Detonating cord O with projectiles every R ❑ without projectile <br /> ❑ Detonating cord and boosters ❑ with projectiles every It ❑ widxxd projectile <br /> ❑ Otho <br /> Sealing Material Neat Cement(941b bag34 gal wafer) , Sand Cement_ sack mW7 gal water Bentonite Pellets <br /> �J/�Bentonita(2DX solids) J Manufacturer Spec%solids_% Name Specs on File i Specs Submitted <br /> Plscdment Method Pumped " Free Fail„, Other <br /> Seal Completion plate with Mushroom Cap� R bgs . Complete to ExlsUng Surface Pad <br /> I HEREBY CERTIFY THAT 1 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 ( ANCE NOTICE REQUIRED FOR INSPECTIONS <br /> CONTRACTORS SIGNATURE TITLE 11I C DA. 1 U.00 O <br /> LAplah I z5tT - <br /> I T <br /> if <br /> 1111 fill <br /> DEPARTMENT USE nut v <br /> Application Accepted By ��/��`i� Date �1 J p�� Area <br /> Destruction Inspection By Date Employee IDI <br /> COMMENTS <br /> PE SC Racelvad Chocks/ Amount I Date PermlV Involve R WIII IDI <br /> Codes Info B Cash Remitted Service Request <br /> EHD 43-08 WELL DESTRUCTION PERMIT <br />