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IAA: �� WELL DESTRUCTION PERMIT 0-17. /;,,: -+' PUBLIC WATER SYSTEM ❑ Yes []No SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 600 E MAIN STREET - STOCKTON CA 95202 - (209) 468-3420 ti (lAl_Denrunwol a DeowT ('Al I f^nCa ev.^ it 7 r- FYPIRFS 1 YFAR FRr)M DATF ISSIIFn JOB ADDRESS / I �T� CITY/ZIP LL A' CROSS STREET O -✓ f T 4L- APN L V. , J CV ' /3 PARCEL SIZE 37•//LAND USE APPLICATION # yy77 Q ,� OWNER �r1E I L % � �� PHONE ? �� L �V '-' OWNER ADDRESSY„- CITY/STATE/ZIP CONTRACTOR'^tr�'S PHONE CONTRACTOR ADDRESS 444 f _CrTYISTATEIZIP 0 t1 rI r !' C-57 WELL DRILLING LICENSE NUR C MBEEXPIRATION DATE �J C PERFORATION CONTRACTOR PHONE PERFORATION CONTRACTOR ADDRESS CITYISTATE/ZIP ❑ C-57 Well Drilling License Number Expiration Date ❑ 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 DESTRUCTION �ogzry ❑ Replacement Well ❑ Caved In ❑ Pit Well ❑ Inactive ❑ Test Hole Detected/Suspected Well Water Contaminant(s) Adjacent property with contamination (Address) Known Soil/Water contaminants at adjacent property EXISTING WELL CONSTRUCTION DETAILS ❑ Open Bottom ❑ Gravel Pack ❑ Uncased ❑ Other Well Log copy attached ❑ Yes '11!� No Grout Seal ❑ No ❑ Yes ft below ground surface (bgs) Hole Diameter inches Well Conductor Casing ❑ Yes X No Depth of Conductor Casing ft bgs Diameter of Conductor Casing inches Well Casing Diameter/ Inches Total Depth _1_,Y ft Depth to Water it Depth of Casing ft bgs DESTRUCTION SPECIFICATION n �',S Sealing Material from i S ft bgs to L ft bgs Filler Material '3 �N �d A/ G /'from it bgs to ft bgs Well casing to be perforated by one of the following methods: from it bgs to ft bgs ❑ Mills Knife Number of cuts every ft and/or ❑ Explosives ❑ Detonating cord ❑ with projectiles everyit ❑ without projectile ❑ Detonating cord and boosters ❑ with projectiles everyft ❑ without projectile ❑ Other Sealing Material Neat Cement (94 Ib bag/5-6 gal water) :. Sand Cement (I sack mix/7 gal water �,,Aentonite Pellets , Bentonite (20% solids) - Manufacturer Spec % solids _ % Name Specs on File Spew Submitted Placement Method Pumped >' Free Fall Other Seal Completion _ Complete with Mushroom Cap Y it bgs Complete to Existing Surface Pad I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE UONE IN AGGUKUANC:E VVIIH 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 . �,U7�/+1, !?'-1— DUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS CONTRACTORS SIGNATURE —Z41Wy TITLE L"'k— DATE r � Z- o -10 Lo L-:jh'oCy tl p RFCE �i aQ(/3 i da L)Siv s APR 07 20 !� 11 ENo vfAir EAr ril lfjojDE M(J Application Accepted E Destruction Inspection COMMENTS DEPARTMENT USE ON Y Date 7 Area Date ! Employee ID#_ PE SC Received Che Amount Date PermiU Invoice # Well ID# Codes IntoB ash Remitted ServiceRe uest # eL3 /S. ' S 2 eb 7,6 9 EHD 43-08 WELL DESTRUCTION PERMIT 10/5/07 r. G A 1