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WELL DESTRUCTION PERMIT <br /> PUBLIC WATER SYSTEM ❑Yes ❑No <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 600 E MAIN STREET-STOCKTON CA 95202 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT i CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS ( t / �l 7 j t 9�hJ CITYrZIP <br /> CROSS STREET l' u i APN d�� ` d`ct(` t l/ PARCEL SIZE LAND USE APPLICATION# C <br /> OWNER �.t IL 1 ) "l" C PHONE m <br /> '7 t• to <br /> OWNER ADDRESS r c-'. CJ CITY/STATE/ZIP <br /> CONTRACTOR '(� 1 PHONE _� /'l <br /> CONTRACTOR ADDRESS 'J /�>/f)L- --r 1� / �j 7 CITY/STATE/ZIP //OeV.;5� <br /> C-57 WELL DRILLING LICENSE NUMBER Z 6a, �� EXPIRATION DATE <br /> PERFORATION CONTRACTOR PHONE <br /> PERFORATION CONTRACTOR ADDRESS CITY/STATE/ZIP <br /> ❑ C-57 Well Drilling License Number Expiration Date <br /> ❑ Bureau of Alcohol,Tobacco and Firearms-Users of High Expl �R <br /> I <br /> i um ' piration Date <br /> ❑ CHP Hazardous Material Transportation for Explosivesro-s I um r E Iration Date <br /> ❑ San Joaquin County Sheriff-Coroner Explosives Application and Permit License Number Expiration Date <br /> ❑ California Occupational Safety Health-Blaster armit I I[�a yetaium&ei e fel �) i Expiration Date <br /> REASON FOR DESTRUCTION Dry ❑ Replacement Well ' �, Rg COn� I�r 135�;Enactive 0 Test Hole <br /> Detected/Suspected Well Water Contaminant(s) r �- <br /> Adjacent property with contamination(Address) <br /> Known Soil/Water contaminants at adjacent property <br /> EXISTING WELL CONSTRUCTION DETAILS ❑ Open Bottom Gravel Pack ❑ Uncased ❑ Other <br /> Well Log copy attached ❑ Yes X No Grout Seal ❑ No ❑ Yes ft below ground surface(bgs) Hole Diameter inches <br /> Well Conductor Casing ❑ Yes )"�No Depth of Conductor Casing ft bgs Diameter of Conductor Casing inches <br /> Well Casing Diameters inches Total Depthft Depth to Water ,.;,:;1' ft Depth of Casing ft bgs <br /> DESTRUCTION SPECIFICATION <br /> Sealing Material from ft bgs to ft bgs Filler Material from ft bgs to ft bgs <br /> Well casing to be perforated by one of the following methods: from ft bgs to ft 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 everyft ❑ without projectile <br /> ❑ Other <br /> Sealing Material . Neat Cement(94 Ib bag/5-6 gal water) Sand Cement sack mix17 gal water Bentonite Pellets <br /> } Bentonite(20%solids) - Manufacturer Spec%solids % Name Specs on File Specs Submitted <br /> Placement Method ❑ Pumped Free Fall - Other <br /> Seal Completion ❑ Complete with Mushroom Cap ft bgs Complete to Existing Surface Pad <br /> I HEREBY CERTIFY THAT I 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 /> f/MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS 7 a <br /> CONTRACTORS SIGNATURE 1 �L C Y'�1.IJZ/.-/� TITLE Ile Q N DATE <br /> AJ- <br /> i 1 REc <br /> ""ERMIT Er P I L) -—T � SAN ZOl <br /> Parmit may have (expired ev"I'l,11lt _ H FnJi°yQIi//v�o <br /> `:-3 k being complete d e ;r P�4`. T--- J-W <br /> TM1 tri � _ <br /> by, E rF�;ranm Tai /� - — -- <br /> _ <br /> g2 on <br /> DEPARTMENT USE ONLY <br /> Application Accepted By_a- "-- - Date Area <br /> Destruction Inspection By Date Employee ID# r^S <br /> COMMENTS <br /> PE SC Received he Amount Date Permit/ Invoice# Well ID# <br /> Codes I Info B Cash Remitted Service Request# <br /> EHD 43-08 WELL DESTRUCTION PERMIT <br /> 10/5/07 <br />