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WELL DESTRUCTION PERMIT <br /> PUBLIC WATER SYSTEM ❑Yes ❑No <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 East Hazelton Avenue-STOCKTON CA 95205-(209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> Joe ADDRESS CrTY21P K&66A Ga <br /> „1 <br /> CROSS ST ET y1 r y�1 qPN ' /� PAR GEL <br /> SIj�ZEj LAND UE APPLICATIONS M <br /> OWNER W PHONE W I <br /> OWNERADDRESS CrTY/STATE/ZIP_j��T+�'7 WA[ON,�O,k/ g93Y0 <br /> .In^ <br /> MA-Ctilis <br /> CONTRACTOR PHONE <br /> CONTRACTOR ADDRESS1Jq CRY/STATEMP MOOM, 60 <br /> Ik C-57 WELL DRILLING LICENSE NUMBERqugv.2— EXPIRATION DATE <br /> PERFORATION CONTRACTOR PHONE <br /> PERFORATION CONTRACTOR ADDRESS CrTY/STATE/ZIP <br /> ❑ C-57 Well Drilling License Number Expiration Date <br /> O 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 A <br /> ❑ California Occupational Safety Health-Blaster License Number Expiration Date A li <br /> REASON FOR DESTRUCTION Dry ❑ Replacement Well ❑ Caved In ❑ Pit Well Cl Inactive ❑ Test Hole <br /> Detected/Suspected Well Water Contaminant(s) <br /> Adjacent property with contamination(Address) �O <br /> Known Soil/Water contaminants at adjacent property 16 <br /> ���/// <br /> EXISTING W CONSTRUCTION ETI ❑ Open Bottom 1p Gravel Pack ❑ Uncased ❑ Other JC) n 2020 <br /> Well Log copy attached ❑ Yes No Grout Seal ❑ No +❑`Yes _It below ground surface(bgs) Hole Diameter L� `1[J N <br /> Well Conductor Casing❑ Yes ❑ No Depth o1 Conductor Casing ft bgs Diameter of Conductor Casing _L7 inchPq EA��//1/>•xI <br /> Well Casing Diamelet_��inches Total Depth 1n(1 k Depth to Water it Depth of Casing it bgs. R L '7 <br /> DESTRUCTION SPECIFICATION <br /> Sealing Material from —U--ft bgs to W.-_ft bgs Filler Material-. __- from_- _it bgs to_ _it bgs <br /> Well casing to be perforated by one of the following methods: from R bgs to it bgs <br /> ❑ Mills Knife Number of cuts every ft and/or <br /> ❑ Explosives❑ Detonating cord ❑ with projectiles every ft ❑ without projectile <br /> ❑ Detonating cord and boosters ❑ with projectiles every ft ❑ without projectile <br /> ❑ Other <br /> Sealing Material I Neat Cement(94 Ib bay5-6 gal wafer) Sand Cement sack mix//gal water Bentonite Pellets <br /> Bentonite(20%solids) ii Manufacturer Spec%solids % Name _ Specs on File Specs SubmittedPlac ment Method Pumped 11Free Fall�r Other <br /> Seal Completion plate with Mushroom Cap it bgs Complete to Existing 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 /> '7e <br /> MI ( *NCE NOTICE REQUIRED FOR INSPECTIONS <br /> CONTRACTORS SIGNATURE TITLE r'I V t 0J W W DATE In.0 -�o <br /> lI I I I <br /> —. _ <br /> i I <br /> DEPARTMENT USE nNI Y <br /> Application Accepted By ��� Data WA, Q CS0 Area <br /> Destruction Inspection B Date !i L Employee IDA <br /> COMMENTS �1 t <br /> PE SC Received Check*/ Amount Date Perm Invoice A Well IDA <br /> Codes Into Cash Remitted Service Request A <br /> E c— IL �0 <br /> EFID 43-06 WELL DESTRUCTION PERMIT <br />