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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)4683420 NON-REFUNDABLE ,PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED l 1 J JOB ADDRESS -�yyam�,, r �r /�,� CRYfZJP__�A mPO � (•"� /S-LZ� CROSS STREETAIR? f RAhA-,-AA-# APN WSt7DOr PARCELSizrq(oLAND U7SEAPPLICATION�g# I' OWNER �FLTN tMi�' PHONE2-0-+ - 3/i1 AVC OWNtR ADDRt'33/L17��S�JA_�/LI✓�]O/'LM /'r r'C� CITYIS7ATE/©ZIP LQI�y_yLedp! 9,�Zy(7 CONTRACTOR //E(XI'/nnj<N' (/�C IL C I/✓G- PHONE 7�J. 3,9Zi^ 7!.'��t6 r I•• CONTRACTOR ADDRESS �O �Q)f Zy3b�s-p CrrY/STATFJZIP SA'G-Td C-57 WELL DRILLING LIcEN3E NUMBER soo g-U Z EXPIRATION DATE / �—1 PERFORATION CONTRACTOR�t�� Dl��L//�/�= PHONE PERFORATI ONTRACTOR ADDRESS CrrY/STATEIZIP C-57 Wei Drilling License Number .l� .J_ Expiration Date fl J 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 DESTRUCTON ❑ Dry ❑ Replacement Wei ❑ Caved In ❑ Pit Well nacttve ❑ Test Hole Detected/Suspected Well Water Contaminant(s) Adjacent property with contamination(Address) Known Soil/Water contaminants at adjacent property FXISTING WELL CONSTRUCTION DETAILS ❑ Open Bottom ❑ Gravel Pack ❑ Uncasec ❑ Other _ Well Log copy attached ❑ Yes �e�No Grout Seal ❑ No ❑ Yes_ft below ground surface(bgs) Hole Diameter1_inches Well Conductor Casing❑ Yes B No Depth of Conductor Casing ft bgs Diameter of Conductor Casing Inches Well Casing Diameter inches Total Depth 125---ft Depth to Water 8 3 ft Depth of Casing �ft bgs DESTRUCTION SPECIFICATION [^ Sealing Material from bgs to��ft bgs Filler Materia ftbgs to ft bgs Well cpI.T16 be perforated by one of the following method • from ft bgs to 57- It bgs Knife _Number of cuts every I and/or ❑ Explosives❑ Detonating cord ❑ with projectiles every ft ❑ without projectile ❑ Detonating cord and boosters ❑ with projectiles every ft ❑ without projectile ❑ Other Sealing Material Neat Cement(94/b bag/5-6 gal water) Send Cement C�_sack mix/7 gal water Bentonite Pellets /1 Bentonite(20%solids) Manufacturer Spec%solids_% Name Specs on File Specs Submitted A Placement Method Pumped Free Fall Other Seat Completion Complete s room Cap �_ ft bgs Complete to Existing Surface Pad ACCC/`N FI HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN //�� D JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. 1 ALSO CERTIFY THAT MY REQUIRED LICENSE It�(I/` CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE IT AF, WORKERS COMPENSATION LAWS. J�N JO� � JO�O MII(IMU 48 HOU AD IANCE NOTICE REQUIRED FOR INSPECTIONS /A q T�z N/N BOG CONTRACTORS SIGNATU ,.[� /�H C gRTT�NTy TfTLE1�117V'A{T`G k-- DATE � 10 Z� MFHT Ja ti 'Po 4 r waw ^� DEPARTMENT USE ONLY Application Accepted By �� Dale -7 Area Area�C1 Li Destruction Inspection,13y Date I<ty � 71 Employee ID# COMMENTS jO N r .., ' rIs rev payide& bri a ' il • e oss;& PE S Received Check#! Amount Permit! Codes Info Cash Remitted Date Service Re ue t Invoice# Well[DO EHD 43-08 � �.�//�� revised 4/14!18 ��•`�I" � WELL DESTRUCTION PERMIT