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WELL DESTRUCTION PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPT PUBLIC WATER SYSTEM 0 Yes No 1868 East Hazelton Avenue - STOCKTON CA 95205-6232 - (209) 468-3420 NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS / .1.4 93 NALA/77/ 0 17 ieti crrazw eAr hi, P en .1'5 - 3.0 -g7 2 , CROSS STREET Rer/44 re.ci APN i fi - AA" - ./i,f)9 PARCEL SIZE l'i YLAND USE APPLICATION # OWNER JiAi144/*/ A 77CoLEL•Ary /44/. hve. PHONE I- 91.s - .5 A 3. — 7- OWNER ADDRESS t7 ())O Ati 4, ri)11 , P14)' Cm/STATE/LP L...41 II ! Dp q.-.33 0 CONTRACTOR CANEFA AND SONS, INC. PHONE (209) 532-1136 CONTRACTOR ADDRESS 14384 CUESTA COURT CITY/STATE/LP SONORA, CA 95370 C-57 WELL DRILUNG LICENSE NUMBER 425749 EXPIRATION DATE 07/3112020 PERFORATION CONTRACTOR PHONE PERFORATION CONTRACTOR ADDRESS CITY/STATE/Zip A C-57 Well Drilling License Number P2 X 791 Expiration Date 7/a//2•00, Bureau of AJcohol, 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 DESTRUCTION 0 Dry 0 Replacement Well 0 Caved In 0 Pit Well As.lnactive 0 Test Hole Detected / Suspected Well Water Contaminant(s) Adjacent property with contamination (Address) Known Soil / Water contaminants at adjacent property EXISTING WELL CONSTRUCTION DETAILS Cl Open Bottom 0 Gravel Pack CI Uncased 0 Other Well Log copy attached 0 Yes C No Grout Seal 0 No 0 Yes ft below ground surface (bgs) Hole Diameter inches Well Conductor Casing 0 Yes C No Depth of Conductor Casing ft bgs Diameter of Conductor Casing inches Well Casing Diameter inches Total Depth ft Depth to Water ft Depth of Casing ft bgs DESTRUCTION SPECIFICATION Sealing Material from I 5D ft bgs to b ft bgs Filler Material (044Q114— from 7,57)ft bgs to 0 ft bgs Well casing to be perforated by one of the following methods: from ft bgs to ft bgs 0 Mills Knife Number of cuts every hand /or 0 Explosives 0 Detonating cord 0 with projectiles every ft 0 without projectile D,etcnating cord.aRd bool5rs 0 with ojectiles every ft El without projectile / ‘,“ 0 Other " . (-41:5,i*ars:J1 c..- ,1 C.A.....e pp --,v-tiL41.. -t Sealing Material Neat Cement (94/b bag /5-6 gal Ater) Sand Cement, .- sack mr4i 7 gal water Bentonite Pellets Bentonite (20% solids)cturer Spec % solids % Name (ia, 1: - Specs on File Specs Submitted Placement Method Pumped Free Fall -,... Other Seal Completion ' Complete with Mushroom Cap f-2:1 ft Ogs Complete to Existing Surface Pad . I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE VV1T1-I 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. mi UM 48 HOUR ADVANCE NOTICE REQUIRED F R INSPECTIONS CONTRACTORS SIGNATURE TITLE Ieti/Deoli 7-- DATE 9/1P/2424,249 DEPARTMENT USE Aki 1 ... iv Date qii °IX a at) Area Destruction Inspection By. Date 1:2-177,-/24r7-0 ID# ti Flo r Oc the (eOirki She'd) n,s+ be. clecoed to er:Zie einY ObSilLai-JOIS 4 COMMENTS i 1) e in 1,4 it i ch t 7 i 1.5h i- in iw fere v., i th El c1-11, tth ni p raerclureS. r PE Codes SC Info Received Check* ,Cash Amount Remitted Date _ , Permit/ Service Request # Invoice # Well ID# 1/i- A-- lei..- Cr 0 WPOO*194/3 :SS 31113.3 V ALS Application Accepted By 3/11 wt t KfaS• 9 S 44 ez,V4 ipfis--117c WELL DESTRUCTION PERMIT EHD 43-08 revised 4/14/15